• PERSONAL TRAINING/ADAPTIVE FITNESS CLIENT INTAKE FORM

  • Rehab Royalty LLC specializes in personal training, adaptive fitness, mobility enhancement, corrective exercise, and post-rehabilitation fitness programming

    (Travel Services Available)

     

  • Disclaimer: Thank you for your interest in Rehab Royalty LLC training services.
    Information collected about new clients is confidential and will be treated accordingly.
    Travel services may vary (limited to D.M.V area/distance within 2-hour radius)
    Gym Location to be disclosed after Inquiry Submission (Washington, D.C.)

    Write "N/A" for street address, if you don't require in-home training

  • CLIENT INFORMATION

  • Gender:*
  • Format: (000) 000-0000.

  • CURRENT FITNESS LEVEL & GOALS

  • Do you require travel services (in-home training)?*

  • HEALTH / PAR-Q FORM

  • Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?*
  • Do you feel pain in your chest when you do physical activity?*
  • In the past month, have you had chest pain when you were not doing physical activity?*
  • Do you lose balance because of dizziness or do you ever lose consciousness?*
  • Do you have a bone, joint, or other health problem that causes you pain or limitations in movement?*
  • Are you pregnant now or have given birth within the last six months?*
  • Have you had a recent surgery?*
  • Do you take any medications on a regular basis?*

  • LIFESTYLE

  • Do you smoke?*
  • Do you drink alcohol?*
  • Describe your job:*
  • Does your job require you to travel?*

  • DEVELOPING YOUR FITNESS PROGRAM

  • If you had to take a break from training, what are the reasons?*
  • Based on your commitment, how often would you like to see a trainer to help you achieve your goals?*
  • What are the best days during the week for you to commit to your exercise program? (check all that apply)*
  • What are the best times for you to exercise?*

  • CLIENT SIGNATURE

    I certify that the information provided is accurate and complete to the best of my knowledge.

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: