Corrective Exercise & Health Coaching IntakeStep 1 of 3

Goals & Background

Training & Injuries

Lifestyle & Consent

Please complete the highlighted fields before continuing.

Basic Information

Contact details

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 Maintain mobility Fortify joints Improve posture Address chronic pain Injury rehabilitation Improve cardiovascular health Improve health span Increase autonomy in late life Learn nutritional habits Plyometrics and explosive power Stress reduction through movement Increase confidence Increase cognitive functioning Increase knowledge about physical health Sports-specific training

Which sport?

Any other goals not listed above?

Please select at least one goal.

How would you rate your current and target physical health?

Current physical health and fitness:

1 = very poor10 = excellent

What rating would you like to achieve?

1 = very poor10 = excellent

Please select both your current and target health ratings.

What would achieving your physical health goals look like for you?

Try to be as specific as possible. What would be different about your life?

A response is required to continue.

Experience Level

What is your experience level in physical fitness?

Select the option that best describes where you are right now.

Complete beginner — little to no prior structured exercise Novice — some experience but inconsistent Intermediate — 1 to 3 years of consistent training Advanced — 3 or more years of consistent training Previously active, returning after a break Athletic background — sport or military

Please select your experience level.

Equipment & Training Background

Which equipment and modalities have you used or would you like to learn?

Check as many as apply in each column.

I have used this

I would like to learn this

Free Weights & Resistance

Barbells

Dumbbells

Kettlebells

Resistance bands

Sandbags

Medicine balls

Machines & Cables

Cable machine

Smith machine

Bodyweight Equipment

Pull-up bar

Parallel bars

TRX bands

Specialty & Functional Equipment

Plyo boxes

Agility equipment (ladders, cones, etc.)

Bosu ball / balance disc

Exercise ball

Foam roller / myofascial tools

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?

Approximately when?

Did you make meaningful progress during that time?

Significant progress Some progress Minimal progress No progress

What worked well?

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. The information you share will give me a thorough picture of any soft tissue changes your body has endured. Really think through your life, and try not to leave anything out.

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:

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 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.

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.

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

Sliding Scale Rates

Do you think you will need to discuss sliding scale rates?

Sliding scale rates are available for those who qualify. If cost is a barrier to accessing services, I still encourage you to reach out, we can discuss other options.

Yes No Unsure

What is your approximate annual household income? This helps us determine eligibility.

Under $25,000 $25,000 to $40,000 $40,000 to $55,000 $55,000 to $75,000 Over $75,000 Prefer not to share

Please select an option.

Additional Information

Is there anything else you would like me to know?

This could include your history, what you need from this work, any medical conditions, medications, or other factors I need to be aware of before we begin.

Consent & Agreement

Please read and confirm the following before submitting

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