Personal Training Interest Form

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Please fill out the form below, and a member of our fitness team will reach out to you. We will do our best to accommodate your requests.

Prior to the start of your personal training sessions, your trainer will review the health questionnaire portion with you. If you marked any of the statements in the below sections, you should consult your physician or other healthcare provider before engaging in exercise.

Thank you!

14Y Fitness Team

PERSONAL TRAINING INTEREST FORM

Name*
First Last
Date of Birth
Email Address*
Address*
Street Address Address Line 2 City State Zip
Phone*
Select the personal training option that you are interested in purchasing.*
- 30-minute sessions
- One-hour sessions
- Partner training sessions (one-hour)
- Jump start package
- None of the above. I'm a new member, and I'd like to have my fitness orientation session.
Do you prefer a female or male instructor?*
- Female
- Male
- No preference
Please select the days of the week that you are available.*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
What times of day are you available?*
- Morning
- Afternoon
- Evening
HEALTH HISTORY
Please answer all questions honestly. Your trainer will review this questionnaire with you prior to the start of your personal training sessions. If you marked any of the statements in the below sections, you should consult your physician or other healthcare provider before engaging in exercise.
History (You have had...)
- A heart attack
- Heart surgery
- Cardiac catheterization
- Pacemaker/implantable cardiac defibrillator/rhythm disturbance
- Heart value disease
- Heart failure
- Heart transplantation
- Congenital heart disease
Current Symptoms
- Chest discomfort with exertion
- Unreasonable breathlessness
- Dizziness, fainting, blackouts
- Take heart medications
Other Current Health Issues
- Diabetes
- Asthma or other lung disease
- Burning or cramping sensation in your lower legs when walking short distances
- Musculoskeletal problems that limit your physical activity
- Take prescription medications that could limit your physical activity
- Pregnant
- Have concerns about the safety of exercise
- Have had major surgery or hospitalization that could limit your physical activity
- Have another medical condition or physical limitation that could limit your physical activity
Cardiovascular Risk Factors
- You are a man older than 45 years
- You are a woman older than 55 years or you have had a hysterectomy or you are post-menopausal
- You smoke or quit smoking within the past 6 month
- Your blood pressure is greater than 140/90 mm/Hg
- You don’t know your blood pressure
- Your blood cholesterol is greater than 200 mg/dl
- You do not know your cholesterol level
- You are physically inactive (i.e. you get less than 30 minutes of exercise on at least 3 days per week.)
- You are more than 20 lbs overweight
Anything else that we should know? (Injuries, goals, etc.)

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Personal Training Interest Form

PERSONAL TRAINING INTEREST FORM

HEALTH HISTORY