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Personal Training
with Britta
Before we get started, I'd like to hear more about you.
Client Intake Form
Name
*
Date
MM slash DD slash YYYY
DOB
*
MM slash DD slash YYYY
Home Phone
Work Phone
Cell Phone
Email
*
Occupation
Do you sit at a desk all day?
Yes
Emergency Contact
Physician's Name
Physician's Number
Are you on any medications? Please list them:
What results do you wish to achieve?
Reduce body fat
Increase fitness
Tone
Strength Training
Sports Conditioning
Weight Loss
Improve Muscle Tone
Stress Management
Improve Flexibility
Reshaping
Rehabilitation
Other
Where do you want to achieve your results?
Thighs
Back
Lower Back
Stomach
Arms
Hips
Buttocks
Shoulders
Waist
Chest
Calves
Other
Other
Other
Do you smoke?
Yes
Are you pregnant?
Yes
Any recent surgeries?
Yes
Have you ever had or experienced?
Heart trouble/history
Pain in the chest
Bone or joint problems
Arthritis
Asthma
Diabetes
Sports Injuries
Chronic Illness
Fainting or dizzy spells
High blood pressure
Back problems
Other
Other
What do you eat for breakfast?
What do you eat for lunch?
What do you eat for dinner?
What are you goals with the OmniFitness program?
Mon-Fri 5:30am-6:15pm
omnifitnessinc@gmail.com
77 Mayflower Rd
Needham, MA 02492
About Us
Services
Partnerships
Certifications
Covid-19
Shop
Contact
