Mobile Personal Training : Health History

Today's Date *
Today's Date
Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Do you currently exercise 2 or more times per week?
What kind of activities do you like or would you like to become involved in? *
Please check all that apply.
Do you have any pain or have you injured any of the following? *
Do you have any medical conditions?
Please check all that apply.
Do you have diastasis recti (ab separation)? *
(ie. heaviness in your pelvic floor, incontinence, urge to pee, leakage, bulging, etc.) If YES, please describe...
If YES, please provide his / her name and your diagnosis.
How would you rate your daily stress level? *
What other health care professionals do you / have you see(n)?
Please check all that apply.
What role would you like your Personal Trainer to play in your fitness and lifestyle program? *
Please check all that apply.
What days of the week would you be interested in meeting with your Personal Trainer? *
Please check all that apply.
What is your preference of time of day? *