Corrective Exercise Intake Form Step 1 of 3

Goals & Background

Training & Injuries

Lifestyle & Consent

Please complete the highlighted fields before continuing.

Basic Information

Full Name

Age

Email Address

Phone Number

Current Occupation or Life Situation

Please enter your name and email address.

Training Goals

What are you hoping to achieve through this work?

Select all that apply.

Lose weight Gain muscle Gain strength Improve balance Improve flexibility Fortify joints Address chronic pain Improve cardiovascular health Improve health span Learn nutritional habits Plyometrics and power development Injury rehabilitation Postural correction Increase knowledge about physical health Stress reduction through movement Sports-specific training

Which sport?

Any other goals not listed above?

Please select at least one goal.

In your own words, what does success look like for you?

Be as specific as possible. What would be different about your day-to-day life?

A response is required to continue.

Please complete the highlighted fields before continuing.

Training History

Have you worked with a personal trainer or corrective exercise specialist before?

Yes No

Where did you train? (gym, studio, online, etc.)

Approximately when?

Did you make meaningful progress during that time?

Yes, significant progress Some progress Minimal progress No progress

What worked well in that experience?

What did not work, or what would you want to be different?

Please select Yes or No.

Do you currently follow any structured exercise program on your own?

Yes No

If yes, briefly describe:

Injury History

Have you experienced any of the following injuries or conditions?

Check all that apply. For each selection, indicate the side affected where relevant.

Rotator cuff tear or impingement

Side:LeftRightBoth

Shoulder labrum tear

Side:LeftRightBoth

AC joint injury (shoulder separation)

Side:LeftRightBoth

Tennis elbow / golfer's elbow

Side:LeftRightBoth

Wrist or hand injury

Side:LeftRightBoth

Neck or cervical spine issue

Side:LeftCenterRight

Upper back or thoracic spine issue

Side:LeftCenterRight

Lower back or lumbar spine issue

Side:LeftCenterRight

Hip injury or impingement

Side:LeftRightBoth

ACL or PCL tear

Side:LeftRightBoth

MCL or LCL tear

Side:LeftRightBoth

Meniscus tear or knee cartilage damage

Side:LeftRightBoth

Patellar tendinopathy or chronic knee pain

Side:LeftRightBoth

Hamstring strain or tear

Side:LeftRightBoth

Quadriceps strain or tear

Side:LeftRightBoth

Achilles tendon injury

Side:LeftRightBoth

Ankle sprain or instability

Side:LeftRightBoth

Plantar fasciitis or foot pain

Side:LeftRightBoth

Sciatica or nerve impingement

Side:LeftCenterRight

Fracture (healed)

Orthopedic surgery

No significant injury history

Please describe any injuries or surgeries in more detail, including approximate dates and whether you received treatment:

Please select at least one option.

Are you currently experiencing any pain or discomfort?

Yes No

If yes, please describe the location, nature, and frequency of the pain:

Please complete the highlighted fields before submitting.

Daily Life & Activity

How much time do you typically spend sitting each day?

Less than 2 hours 2–4 hours 4–6 hours 6–8 hours More than 8 hours

Please select an option.

How would you describe your overall daily movement, outside of structured exercise?

Mostly sedentary (desk job, minimal walking) Lightly active (some walking, occasional standing) Moderately active (regular walking, active errands) Very active (on feet most of the day, physical job)

Please select an option.

How often do you currently exercise in a structured way?

Never Rarely (once a month or less) Occasionally (1–2 times per month) Sometimes (1–2 times per week) Regularly (3–4 times per week) Daily or near-daily

Please select an option.

What types of exercise or movement do you currently enjoy or engage in?

Check all that apply.

Walking or hiking Running Cycling Swimming Weight training Yoga or Pilates Sports (recreational) None currently

Are there any activities or movements that currently cause you pain or that you actively avoid?

Health Ratings

How would you rate your current physical health and fitness?

1 = very poor10 = excellent

What rating would you like to achieve through this work?

1 = very poor10 = excellent

Please select both your current and target health ratings.

Additional Information

Are there any medical conditions, medications, or other factors I should be aware of before we begin?

Is there anything else you would like me to know about you, your history, or what you need from this work?

Consent & Agreement

By typing your name below, I confirm that I have read and agree to the following:

I understand that corrective exercise and personal training are not substitutes for medical care, diagnosis, or treatment. I will consult a physician before beginning any exercise program if I have concerns about my health.
I take full responsibility for my own participation and will communicate openly with my trainer about any pain, discomfort, or limitations during sessions.
I may discontinue services at any time, in accordance with the terms of my service agreement.
All information shared will be kept strictly confidential and used solely to inform my training program.

Full Name (digital signature)

Date

Please check all consent boxes and type your full name.

Thank you.

Your intake form has been received. I will be in touch within 1–2 business days to discuss your program and schedule your first session.

Thank you.

IMPASSE LIFE RECOVERY