Home
About
Fitness Plan
Book Tattoo
Art
TikTok
Aftercare
FAQ
Menu
Buyan
Street Address
City, State, Zip
Phone Number
Buyan Isle + Movement
Your Custom Text Here
Buyan
Home
About
Fitness Plan
Book Tattoo
Art
TikTok
Aftercare
FAQ
Get your personal fitness plan
Personal coaching in Mount Pleasant
Please complete the form below and I’ll follow up.
Name
*
First Name
Last Name
What name should I use for you?
*
Pronouns
Gender (optional)
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
What do you do for a living?
*
What is the activity level of your job(s)?
*
Low (seated or standing)
Moderate (walking)
High (very active/heavy labor)
Please list injuries if you have them, on what side of the body, and for how long you've had them
What treatment or therapy is being undertaken for injuries?
Please list if you have any diagnosed conditions or diseases
What treatment or therapy is being undertaken?
Please list any medications, vitamins or supplements you take
*
Do you feel pain while exercising or moving?
*
If yes, please share where, what side of the body, for how long, what the pain feels like
Have you had any surgery since one year from today?
*
If yes, please share what surgery, and when it was
Do you have disability or accessibility needs you'd like me to be aware of?
*
Are you interested in or comfortable exercising outside weather permitting?
Yes
No
How often do you exercise per week?
*
How often can you commit to exercise per week as your baseline? Would you like regular sessions (weekly, biweekly, monthly) or would you like a custom program to do on your own with spaced out checkins?
*
Select the days you can exercise indoors
*
Wednesday
Thursday
Friday
Saturday
Select days you can exercise outdoors (ignore for winter)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Select the times you can exercise
*
Early Morning 9-10
Morning 10-12
Early Afternoon 12-2
Late Afternoon 2-4
Evening
What goal(s) best fit with your goal?
*
Strength
Flexibility
Reduce stress
Minimize pain
Training for an event
Endurance
Other
What is your goal or goals with your training?
*
Why?
*
What are your expectations of me as your personal trainer?
Testimonial
*
Are you open to sharing a testimonial of your experience at the end of your program?
Yes
Maybe
No
Is there anything you'd like to share or add?
I, hereby acknowledge that the information I've given above is complete and accurate to the best of my knowledge. I understand all the risks and I accept full responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.
*
Yes
No
Date
*
MM
DD
YYYY
Client Signature
*
First Name
Last Name
Thank you!