Online Training Program Intake Form
Payment
Online App-Based Training: $80/month.
I acknowledge that payment is required for continued access to programming and coaching.
*
Cash App $EricaJordan901
Apple Pay 901-937-9441
Zelle 901-937-9441
Client Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text Message
Desired Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Fitness Goals
Primary fitness goal
*
Fat loss
Body recomposition
Muscle gain/definition
Strength
Endurance
General fitness
Other
Specific goals you would like to achieve
Current activity level
*
Please Select
Sedentary
Lightly active
Moderately active
Very active
Extremely active
Days per week you currently exercise
*
Training Experience & Access
Current training experience level
*
Beginner
Intermediate
Advanced
Do you currently have a gym membership?
*
Yes
No
Where do you plan to complete your workouts?
*
Gym
Home
Both
Equipment available to you
Dumbbells
Resistance bands
Kettlebell
Barbell
Bench
Pull-up bar
Cardio machine
Yoga mat
Cable machine
None
Other
Exercises you especially enjoy or dislike
Health & Safety
Current or previous injuries or physical limitations
None
Back
Knees
Shoulders
Neck
Hips
Ankles/Feet
Wrists/Hands
Other
Medical conditions, recent surgeries, or medications that may affect exercise
None
Asthma
Diabetes
High blood pressure
Heart condition
Joint condition
Recent surgery
Pregnancy/Postpartum
Medication that affects exercise
Other
Please explain any selected items or additional health concerns
Has a healthcare professional placed any restrictions on exercise?
*
No
Yes
Unsure
Please obtain medical clearance before starting or continuing exercise when appropriate. This form is for screening purposes only and does not replace medical advice.
Nutrition
Nutrition guidance note
Current nutrition habits
Dietary preferences
Balanced/General fitness nutrition
High protein
Low carb
Vegetarian
Vegan
Pescatarian
Dairy-free
Gluten-free
Other
Food allergies or intolerances
Foods you avoid or dislike
Average daily water intake (cups per day)
Biggest nutrition challenge
Supplements
Do you currently take any supplements?
*
Yes
No
If yes, list the supplements you take and how often you use them
App-Based Training
Which version of the online training program would you like?
*
Home-Based Program
Gym-Based Program
Do you have a smartphone or tablet and reliable internet access to use the app?
*
Yes
No
Are you comfortable following video demonstrations independently?
*
Yes
No
Need support
Questions about the app
Weekly Check-Ins
Weekly check-ins are conducted every Sunday.
Most Helpful Accountability/Support
*
Progress review
Workout adjustment
Nutrition guidance
Motivation check-in
Habit tracking
Message support
Other
Client Acknowledgment & Consent
I acknowledge and agree to the statements above
*
I confirm the information I provided is accurate; I understand the program structure, price, app-based delivery, weekly check-ins, nutrition and supplement guidance; I understand exercise carries inherent risks; I agree to communicate injuries, pain, medical changes, or limitations; and I understand results vary and are not guaranteed.
Full Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Enrollment
Submit Enrollment
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