Dave Long Fitness - Intake Form

First Name

Last Name

Phone

Email

Emergency Contact

Emergency Contact Phone

Health History

Other (please specify, if none put N/A): *

2. Have you had any surgeries in the past 5 years? *

Yes

No

If yes, please explain:

3. Do you currently take any medications? *

Yes

No

If yes, please explain:

4. Do you experience any of the following symptons (Select all that apply) *

5. Are you pregnant or planning to become pregnant during your training? *

Yes

No

Fitness Goals

1. What are your main fitness goals? (Select all that apply) *

Other (please specify):

2. What motivates you to pursue these goals? *

3. How would you rate your current fitness level? *

Exercise Preferences and History

1. How often would you like to work out? *

2. What types of exercies do you enjoy or prefer? (Select all that apply) *

3. What types of exercise do you dislike or prefer to avoid?

4. Do you have access to a gym or fitness equipment? *

Yes, gym membership

Yes, home gym

No

If Home Gym, please list ALL equipment you currently have or can get access to for your workout program (i.e., dumbbells, resistance bands, kettlebells, etc.):

5. Do you have any injuries or conditions I should be aware of that may affect your workout? *

Yes

No

If yes, please explain:

Lifestyle and Availability

1. How many hours of sleep do you typically get per night? *

2. How would you describe your current diet? *

I eat a balanced diet with fruits, vegetables, and lean proteins

I eat fast food or processed foods often

I try to eat healthy but struggle with consistency

I follow a specific diet plan (e.g., keto, vegan, etc.)

Other

3. How much stress do you experience on a daily basis? *

4. Do you have any specific concerns I should be aware of before starting your fitness program? *

Commitment and Accountability

1. Will you be comfortable communicating through the Trainerize app (DM functionality) for weekly updates? *

2. On a scale of 1-10, how committed are you to achieving your fitness goals? *

3. Do you have any specific deadlines or events (e.g., wedding, vacation, etc.) you are working toward? *

If yes, please specify:

Empowering Your Path to Health

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Phone: (856) 334-9009

Email: [email protected]

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