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Personal Training Intake Form

  1. Gender

  2. Preferred Trainer

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

  4. Are you taking any medications or drugs?*

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

  6. *Increased blood pressure?

  7. *Diabetes or a thyroid condition?

  8. *History of heart problems in immediate family?

  9. Any chronic illness or condition?

  10. Difficulty with exercise?

  11. Advice from physician not to exercise?

  12. Surgery within the last 12 months?

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

  14. History of breathing or lung problems?

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

  16. Cigarette smoking habit?

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

  18. Increased blood cholesterol?

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

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

  21. Leave This Blank:

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