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Personal Training Intake Form

  1. Gender

  2. Preferred Session Times

  3. Preferred Trainer

  4. Participant's Health History

  5. Does your physician know you are taking part in this exercise program?

  6. Are you taking any medications or drugs?*

  7. Do you now have, or have you had in the past: (Please explain "yes" answers in comment section at bottom of form.)

  8. *History of heart problems, heart attack, chest pain, or stroke?

  9. *Increased blood pressure?

  10. *Diabetes or a thyroid condition?

  11. *History of heart problems in immediate family?

  12. Any chronic illness or condition?

  13. Difficulty with exercise?

  14. Advice from physician not to exercise?

  15. Surgery within the last 12 months?

  16. Pregnancy? Now or within the last 3 months?

  17. History of breathing or lung problems?

  18. Muscle, joint, or back disorder, or any previous injury still affecting you?

  19. Cigarette smoking habit?

  20. Obesity? More than 20% over ideal body weight?

  21. Increased blood cholesterol?

  22. Hernia or any condition that may be aggravated by lifting weights?

  23. Have you had any pain or discomfort with exercising in the past?

  24. * If an asterisk question is marked yes, a physicians release form must be completed and signed before personal training sessions can begin. Please have your physican fax the form to Suzi Shankweiler at 303-833-7068. A certified trainer will call you to set up an appointment within 72 hours of submitting this form.

  25. Leave This Blank:

  26. This field is not part of the form submission.