Personal Training Intake Form
Jake Westhoven, Jessi Westhoven, Personal Trainer, Physical Therapy Assistant
Insured (by Alternative Balance Group, LLC)
Licensed by the Physical Therapy section of the OTPTAT Board of Ohio
Today’s date: ______________
Name: ____________________ Age: ______
Address: _____________________________________Town: _________________ State: ___ Zip: ______
Phone Number(s): __________________________________________________________________________
Email (optional): ___________________________________________________________________________
Circle: Male Female – Any chance you are pregnant? Yes / No
Any history of spinal injury or injury to a joint or muscle? ________________________________________________________________________________________ _________________________________________________________________________________________
Does it still affect you? Please describe: __________________________________________________________________________________________________________________________________________________________________________________
The following section will be completed by the trainer at the initial consultation:
Current Bodyweight: _______ lbs.
Current Body Fat Percentage _________ %
Height: ____ ft _____ inches
Resting Heart Rate: ______ bpm
What is your blood pressure? _______________ Unknown
Waist ______ inches
Hips ______ inches
Legs (left) ______ inches (right) ______ inches
Upper Arm (left) ______ inches (right) ______ inches
Forearms (left) ______ inches (right) ______ inches
Calves (left) ______ inches (right) ______ inches
Shoulders ______ inches
Neck ______ inches
Chest (men only) ______ inches
What are your current health/fitness goals? _________________________________________________________________________________________
What are the main reasons for your goals? _________________________________________________________________________________________
Circle any symptoms of possible coronary or metabolic disease you have recently experienced:
Chest pain shortness of breath dizzy/fainting ankle swelling heart palpitations leg/feet cramping heart murmur
Risk factors for CHD (Coronary Heart Disease), MI (heart attack), Stroke or hypertension (usually caused by atherosclerosis)
Do you smoke? Yes No
How much? ____________ per day week month
Did you quit smoking less than 6 months ago? Yes No
Do you take: Antihypertensive medications? Yes No
Are you currently taking Beta-blockers? Yes No
Do you get at least 30 minutes of moderate physical activity everyday? Yes No
Do you have: Osteoporosis? Yes No
Osteoarthritis? Yes No
Do you suffer from back pain? Yes: Upper Mid Low No
How often? Rarely Daily Weekly Monthly
Are you often stressed? Yes No
How does it physically manifest? Headache Stomach Sleepless Irritable Other ________________
How many times do you get sick (common cold) per year?
1 2 3 4 More! _______
Do you have diabetes? Yes: Type I Type II No
Are you taking any medications? List: _________________________________________________________________________________________
Do you eat low, moderate or high carbs? Low Mod High
Do you eat low, moderate or high protein? Low Mod High
Do you eat low, moderate of high fat? Low Mod High
Do you eat a variety of foods (whole grains, dairy, lean meats, fruit & vegetables with limited fat/oils)? Yes No
How many calories do you need per day? ____________ Kcal (Men = Weight x 10.5; Women = Weight x 9.0)
How many calories do you eat per day? ____________ Kcal
What level of importance do you place on exercise?
None Low Average High Essential
How often do you currently exercise? _________________________________________________________________________________________
What type(s) of exercise do you usually perform? _________________________________________________________________________________________
How many days per week do you want to commit to exercise?
1 2 3 4 5 6 7
How many minutes per day?
20 or less about 30 45 60 an hour (+)
Rate your fitness (1-Poor, 5-Average, 10-Excellent):
Cardio-Respiratory 1 2 3 4 5 6 7 8 9 10
Strength 1 2 3 4 5 6 7 8 9 10
Endurance 1 2 3 4 5 6 7 8 9 10
Flexibility 1 2 3 4 5 6 7 8 9 10
Power 1 2 3 4 5 6 7 8 9 10
Body Composition 1 2 3 4 5 6 7 8 9 10
Self-Image 1 2 3 4 5 6 7 8 9 10
Congratulations! You are making a commitment to invest in your health and well-being.
Please read the following and sign below to acknowledge your understanding and consent.
In order to assess your general health risk and tailor the training process to your individual needs, you will be asked questions about your, and your family’s, health history. Your privacy is respected. Your information will never be shared without your advanced written consent (except in the event of a medical emergency) and will not be used for any purpose other than adjusting your fitness training program and assessing your health risk as it pertains to your training. An educated trainer is better able to help you safely meet your goals.
In addition, as part of the assessment process, you will be asked to perform one or more tests to measure your level of fitness in several categories (i.e., cardiopulmonary, flexibility, strength, endurance and power). This testing can be as strenuous as exercise and will recur as needed to gauge your progress. Results are compared to norms and your prior results to measure success and keep you motivated.
The assessment process and training sessions include taking measurements and correcting form. Some measurements and/or correction of form may involve appropriate physical contact between you (the undersigned) and the trainer. You will be asked to give verbal permission before any physical contact is initiated.
Proper exercise is fundamental to a long, active and healthy life. The training sessions will involve mild, moderate or even strenuous exertion of your physical body. Intensity will be monitored by the trainer and customized to your health and tolerance. However, any physical activity can result in injury or death for reasons beyond the control of the trainer. Your signature below acknowledges you agree to be honest and forthcoming by reporting any medical history, conditions or injuries that may increase your risk of further injury, illness or death. Communicate whenever you are uncomfortable or in pain so your activity can be modified for your health and safety.
It is recommended that you eat a balanced, light meal or energizing snack 30-45 minutes prior to any workout and that you drink plenty of water all day to stay hydrated. When exercising, wear sneakers and loose-fitting and/or supportive clothing (as needed) in which you will be comfortable during the motions and positioning that are part of the training sessions.
Sign: _______________________ Print: ________________________ Date: _____________