Manchester CT Personal Training by Balance Fitness & Health, LLC

Balance Fitness Intake Form

Name*

D.O.B //*

Address*

City*

Zip*

Contact Number:*

E-Mail:*

Your Goals

As detailed as possible, please describe the fitness goal you would like to achieve:*

When would you like to achieve this goal by?*

What has held you back from achieving this goal in the past?*

Do you consider yourself a project starter or a project finisher?*

Do you view yourself as a person capable of exerting self-discipline and creating new habits?*

What’s the best way that we can help you achieve your goals?*

Medical/ Orthopedic Concerns

Are you currently taking any prescription medications I should be aware of?*

Do you have orthopedic/ muscular concerns or diagnoses?*

Do you have any condition(s) that could worsen by participating in physical activity ?*

Fitness Evaluation

Are you currently exercising?*

How long have you been exercising/training?*

Do you suffer from back pain? (upper/middle/lower)*

Do you have any injuries or limitations?(knee, shoulder, etc)*

Is there anything physically that you cannot do, what you have always wished you could do?*

Please give details of any training for the past 12 weeks. (please be detailed) *

Nutrition Evaluation

Do you have any food sensitivities/allergies you are aware of?*

What foods, if any cause bloating/distention?*

Do you have sugar or salt cravings?*

If you answered yes, what time of day do you have cravings

How would you describe your relationship with food?*

Can you provide details of current diet habits.*

Are you currently taking any supplements?(multi-vitamin, D3,....etc)*

How much water do you consume daily?*

How many caffeinated drinks do you consume on a daily basis? (coffee / tea / energy drinks / soda) *

Sleep Evaluation

Do you have trouble falling asleep?*

Do you struggle to wake up in the morning?*

Do you sleep less than 8 hours a night?*

Do you wake up once or more during the night? *

What time do you wake up if you do?*

Do you sleep in a room with any light or noise?*

Do you go to bed later than 11 pm?*

Do you use medications(OTC or PX) for sleep?*

Do you often have a midday crash in energy? *

How would you rate your daily stress level on a scale 1-10(1 being minimal stress)? *

Let's work together to reinforce your goals and healthy lifestyle. Your continued commitment will give you the consistency needed to reach your goals.

We have received your message and will get back to you as soon as possible.

Intake Form

Balance Fitness Intake Form

Our Services

Gym Hours