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Personal Training Client Intake Form

Let's start with the basics.

What is your first and last name?

How do you identify?

How do you identify?
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B
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D

How would you like me to refer to you?

How would you like me to refer to you?
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B
C
D

When is your birthday?

What is your phone number?

What is your email address?

What is your address?

Let's dive deeper.

What are your goals?

What are your goals?

List any concerns you have about your health, fitness, and/or body.

Please list all of the obstacles you feel like you're facing when it comes to achieving your goals?

What kind of exercise do you currently do and how often?

Which trainer do you want to work with?

Which trainer do you want to work with?
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B
C

Ideally, how many days per week would you like to train?

What's your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

What, if any, significant medical condition(s) and/or injuries have you been diagnosed with (currently or in the past)?

What, if any, specific health concerns, such as illnesses, pain, and/or injuries do you have?

What, if any, medications, either over-the-counter or prescriptive, are you taking?

On a scale of 1-10, how would you rank your health right now?

On a scale of 1-10, how would you rank your health right now?

Disclaimer

RELEASE AND INDEMNITY
The Client has hired Union Osteopathy Inc. for advice and guidance on a training program
which will involve strenuous physical activity.
The Client acknowledges that before engaging in any physical training program that
he/she/they should consult with a medical doctor.
Union Osteopathy Inc shall not be liable for or responsible in any way for personal or
consequential injuries of any kind that is suffered or sustained by the Client.
Union Osteopathy Inc. wishes to ensure that the Client is aware of this and has requested this
Release and Indemnity from the Client as assurance that the Client will not hold Union
Osteopathy Inc. liable for any costs, losses or damages arising from any injury or loss of any
kind suffered as a result of participation in this physical training program.
The Client, therefore, his/her/their successors and assigns, hereby releases and discharges
Union Osteopathy Inc. from all actions, causes of action, claims and demands whatsoever,
including all claims for compensation for personal injuries, loss of time, loss of wages, loss of
profit, expenses, including medical expenses, all whether present, past or future, and any
aggravation, foreseen or unforeseen, as well as for any damages presently undisclosed and all
demands and claims of any kind or nature whatsoever arising out of or in any way connected
with the training program at Union Osteopathy Inc.
The Client declares that the terms of this Release and Indemnity are fully understood by the Client.
By clicking the yes button below, you're agreeing to the disclaimer and that all of the information you've provided above is accurate and up to date to the best of your knowledge.
Untitled multiple choice field
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B

Scheduling Your Session

Once we receive your form, you'll get an email with instructions on scheduling your 1st Personal Training session.