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Personal Training Client Intake

Thank you for your interest in our Personal Training program with EIU Campus Recreation. Please fill out the information below to get started. After completion of this form, your personal trainer will contact you by a phone call within 5 business days of submission of your application. During this call, your trainer will work with you to set up your free 30-minute consultation appointment. After the initial consultation appointment and purchase of a personal training package/session, you will be ready to work with your personal trainer

Name Name First Last
Today's Date Today's Date / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Gender
Date of Birth Date of Birth / MM / DD YYYY
E#
Why are you interested in working with our personal trainers?
What are your three main fitness goals?
What types of physical activities interest you? Ex: walking, playing soccer, lifting weights, rowing, etc.聽
What physical activities do you currently participate in?
On a scale of 1-5, with 1 being very little and 5 being extremely, how stressed would you say you are?

On a scale of 1-5, with 1 being very little and 5 being extremely, how stressed would you say you are?
1 2 3 4 5
How do you deal with stress?
How many times a day do you eat?

How many times a day do you eat? 1 2 3 4+
How many hours do you work per week?

How many hours do you work per week? 0-10 10-20 20-30 30-40 40+
On a scale of 1-5, with 1 being very poor, and 5 being very good, How is your overall work-life balance?

On a scale of 1-5, with 1 being very poor, and 5 being very good, How is your overall work-life balance?
1 2 3 4 5
What are the conditions of your work/school?

What are the conditions of your work/school? Sitting Standing Moving around Other Other
Are you currently an EIU student? If yes, what year are you and how many credit hours are you taking?
Are you interested in participating in Partner Training (two clients, one trainer sessions)? If yes, please include the name of the person you would like to do this with below.
Please provide three days and times that you would be able to work with your trainer?
If you have a gender preference for your trainer, please list this down below.
How many times per week would you be interested in working with your trainer?

How many times per week would you be interested in working with your trainer? 1 2 3 4+
Please provide any additional information you feel that your trainer should know. For example, medical history, surgeries and injuries, exercise limitations, etc