New Client Questionnaire

General Info

Name

Email

Phone

City/State

Birthday/Age

Height/Weight

What type of personal training are you interested in?

How much time can you commit to your workout program (e.g. 2x/week, daily, etc.)? This is how often you will workout, not how often you will have training sessions with us.

Where will you workout (e.g. home, gym, traveling)?

Do you currently have any exercise equipment you like to use (e.g. dumbbells, treadmill, ball)?

Will you consider purchasing small exercise equipment (e.g. dumbbells, ball, bands)?

What is your current/past exercise history like?

What are your new health/fitness goals?

How did you find us?

Do you have a preference between working with Dana or Jeff?

Date you want to start your program:

Please answer correctly: 3+2=? 

Cardiac Risk Factors

Do you have any heart conditions?

Do you have high blood pressure?

Family history of heart conditions?

Stress levels (low, medium, high)?

Do you smoke?

Activity level per week?

Orthopedic Conditions / Injuries

Cervical Spine

Thoracic Spine

Lumbar or Sacroiliac

Shoulders

Elbows, Wrists, Hands

Hips

Knees

Ankles, Feet

Sciatica

Anything else you want to share: