Audrey's personal training intake form

Full Name*

First NameLast Name

Gender*

MaleFemale

Date of Birth*

MonthDayYear

Height*

Inches

Weight*

lb

Day Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

E-mail*

What is the best way to make contact with you?

Physician's name & address*

Physician's phone

Date of last physical exam

Date

Emergency Contact*

Relationship

Emergency Contact cell phone*

Area CodePhone Number

Emergency Contact email

example@example.com

Please list the physical activities that you participate in outside of the gym and outside of work.:

If you have any diagnosed health problems list the condition(s).*

If you are on any medications, please list them.*

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.*

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

YesNo

Has anyone of your immediate family developed heart disease before the age of 60?*

YesNo

Do any medical issues run in your family?*

YesNo

Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo

If yes please list:

Are you a current cigarette smoker?*

YesNo

Your current diet could be best characterized as:

Which of the following goals best fit in with yours (select all that apply)?*

What personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?*

Do you currently exercise on a regular basis?*

YesNo

What equipment do you have access to at your house?*

What days are you available to train?*

Have you had any recent weight gain or loss?*

YesNo

If yes, please explain:*

Type "N/A" if not applicable

How did you hear about me?*

CANCELLATION POLICY

I understand that life can be extremely busy ~ and am thrilled that you reserve time with me to help you take care of yourself!

In the event that you need to cancel an appointment, I kindly request that you do so with 24 hours notice. The time slot that I reserve for you is yours alone, and I am often unable to re-book it if you cancel last minute. If you cannot attend your time and are unable to find a replacement, you may be asked to pay for the session. I appreciate your understanding of this policy.

LIABILITY

I acknowledge the inherent risks involved in any type of fitness program. I fully understand that I will be engaging in activities that involved risk of injury. I expressly assume all risks of injury, which may occur in connection with my participation in personal training sessions with Audrey Epstein and release her of responsibility.

ACKNOWLEDGEMENT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

I agree to the above terms and conditions:*

Yes

Signature*

Please Read The Following T&C's.