Your Fitness Journey Starts Here

Personalized Fitness Program Intake Form

Welcome to Exercise Nation USA! We are excited to guide you on your fitness journey. To create a program tailored to your unique goals and needs, we ask that you fill out this intake form. Your responses will help us better understand your health, preferences, and lifestyle, ensuring a customized experience.

This form will take approximately 10 minutes to complete.

Why Your Input Matters:

Helps us design a program perfectly suited to your goals.
Ensures we address your specific fitness and health needs.
Creates a foundation for success on your fitness journey.

Thank you for your time and trust in us!

Terms and Conditions:

By participating in this survey, you agree to the following:

Your responses will be used solely to design your personalized fitness program.
All information provided will be kept confidential and not shared with third parties.
Participation is voluntary, and you may exit the survey at any time.
By proceeding, you consent to the collection and use of your responses as outlined above.

I have read and agree to the terms and conditions.

About You

Full Name *

Email *

Date of birth

Phone

City

State

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Health and Medical History

Do you have any current or past medical conditions?

Are you currently taking any medications?

Do you have any injuries or physical limitations?

Have you had surgery in the last 12 months?

Do you experience pain during physical activity?

Has a doctor advised you to avoid specific physical activities?

Fitness Goals

What are your primary fitness goals? (Select all that apply): *

Do you have any other goals apart from the above?

Why are these goals important to you?

What is your timeline for achieving these goals?

Current Fitness Routine

Are you currently exercising regularly?

Yes

Please describe your exercise routine

How many days per week do you exercise?

What type(s) of exercise do you engage in?

Cardio

Strength training

Yoga

Pilates

Are you doing any other type of exercise apart from the above?

How would you rate your current fitness level? *

Beginner

Intermediate

Advanced

Do you participate in recreational activities or sports?

Dietary Habits and Nutrition

How many meals and snacks do you eat daily? *

Meals
Snacks

Do you track your calorie or macronutrient intake? *

Yes

Do you have any dietary restrictions or food allergies?

Do you take vitamins, supplements, or herbal remedies?

Lifestyle and Habits

What is your occupation?

On average, how many hours of sleep do you get per night? *

5-6

7-8

How would you rate your stress levels?

Low

Moderate

High

Do you have access to a gym or fitness equipment?

Preferences and Expectations

What type of workouts do you enjoy or dislike? *

Enjoy
Dislike

Do you prefer working out indoors, outdoors, or both? *

Indoors

Outdoors

If you worked with a trainer, would you like to receive video reports of your sessions?

Yes

Are there specific exercises or equipment you’d like to include in your program?

What motivates you to stay consistent with your fitness goals? *