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1

Sign Up Today!

First Name

Last Name

Age

City/State

Phone number

Email

2

Gender

Female

Male

3

Type of Training Interested In?

Private 1 on 1 (in-person)

Online Virtual Training

Group Training

4

For individuals who are purchasing virtual/online training, what gym membership do you have and/or what workout equipment do you have at home?

5

Do you have any prior injuries, surgeries, or illnesses that require specialized care? If so please lists dates associated with the injury/diagnosis.

6

What are the results that you want to achieve?Goals

Ex: (Gain confidence and lose weight or learn proper exercise technique and gain lean muscle mass)

7

Have you had a trainer or rehabilitative care before? If so what were the dates/types and results achieved? Also, what did you like/dislike about the training?

8

What are the roadblocks/obstacles holding you back from your goals?

9

When can you commit to begin working on your goals and start the program?Please type date below

10

When is your preferred time for sessions?

Morning

Afteroon

Evening

11

How would you rate your nutrition?

Poor

Fair

Good

Excellent

12

Why did you give yourself the nutritional rating in the previous question? Explain what is going well and what needs improvement with your nutrition.

14

How did you hear about OT Movement Mastery?