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Work With Me
Personal Training
Small Group Personal Training
About
Success Stories
Blog
Contact
Intake Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
How did you hear about me?
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Word of Mouth
Instagram
Facebook
Email
I can't remember
What would you like to get our of our time together?
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What do you think may get in the way of you achieving your goals? (This is the time to be honest, and together we can figure out a way to navigate your obstacles.)
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How committed are you to achieving your goals?
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Very Committed
Somewhat Committed
I'm not sure
Tell me about your relationship with exercise. (Does it make you nervous? Do you feel unsure on what to do? Do you love it?)
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Do you have any mental health concerns? (All answers are kept in strict confidence)
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How much stress do you experience on a day to day basis?
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High
Moderate
Low
How much energy do you have on a day to day basis?
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I have energy to burn!
I have an average amount of energy
I constantly feel low on energy
Help me understand more about your capabilities. Rate how difficult the following tasks would be - the first is walking up three flights of stairs.
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Extremely Challenging
Somewhat Challenging
Not challenging at all
Getting down to the floor then back up again
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Extremely Challenging
Somewhat Challenging
Not challenging at all
Doing three push ups on your knees
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Extremely Challenging
Somewhat Challenging
Not challenging at all
What do you expect from your trainer?
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Is there anyone in your family under 60 years of age who has suffered from heart disease, stroke, irregular cholesterol or sudden death?
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Yes
No
Are you a smoker?
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Yes
No
Do you have any major health conditions?
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Yes
No
If yes, provide details
Do you have or have you ever had?
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Dizziness / Fainting
High / Low Blood Pressure
Chest pain
Asthma
Arthritis
Unusual Shortness of Breath
Any significant injuries to any part of your body? (current or past)
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Is there anything else you'd like me to know?
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details have health
If you have a health condition please ask for written clearance from your doctor and bring this form to your initial consult, or sign with your name or initials below if you have already cleared your conditions with your doctor.
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Checkboxes
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I recognise that Fit With Sally is not able to provide me with medical advice in regard to the suitability of my participation in an exercise program. I have answered the questions to the best of my ability and understand the above advice. I, being aware of my own health and condition and having knowledge that participation in any physical activity carries an element of risk, accident and injury and I am voluntarily participating in the fitness training program offered by Fit With Sally, it’s trainers and associates which has been presented to me in written form. Having such knowledge, I hereby release Fit With Sally, it’s representatives, agents, employees and successors from liability for accidental illness or injury which may incur as a result of participation in the said fitness program. I hereby assume all risks connected therewith and consent to participate in the said program. Please sign below with your full name.
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