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Personal Training Intake Form

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1) Please tell me your expectations for personal training, i.e. do you want a workout or several workouts that you can do on your own at home, or at a gym; do you want to come in for training on a regular basis to supplement the work you are doing on your own, or come in once a month to "tune up" your workout, or anything else.*

2) What are your fitness goals? Some examples could be: perform a regular strength and conditioning program every day or 3-4 times a week; get outside more often; build upper body strength; strengthen my core to prevent back pain; or train for an event.*

3) Please tell me what you are doing for exercise currently and how you feel about your current exercise level--i.e. 1) I have a good routine that can use some updating;2) I need to be more active; 3) I am exhausted by the amount of exercise I do but I need it mentally, for weight control, or for other reasons.*

5) If you have experience with strength-building exercise, please give me an idea of any form of exercise you particularly like/dislike. For example, do you enjoy/detest weight machines, body weight exercises, handheld/free weights, HIIT? Keep in mind that exercises we hate because they are uncomfortable and tiring sometimes are the ones we need the most. Your answers, however, will help me design a program that you are most likely to stick with!*

4) Please list any current and past injuries or pain issues, past medical issues, and all medications you are taking currently. All information is kept confidential, and under my care you are HIPPA privacy protected. Exercise can affect the metabolism of some medications and alter their effect, and also in some situations, lower your response to exercise. This is very important information.*

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Points North Sports & Regenerative PT
435 Points North Rd.
Stowe, VT 05672

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Phone: (203) 260-0215
Fax: (802) 264-8519
Email: info@pointsnorthphysicaltherapy.com