Beach Cities Health District
Center for Health & Fitness
Adventure Plex
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Find a Trainer
Contact Information
First Name:
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Last Name:
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Phone Number:
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Email:
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General Information
Please select your primary health and fitness goals:
Lose weight/body fat
Build muscle
Injury/surgery rehabilitation
Sports-specific training
Function/balance training
Pre/post-partum fitness
Disease management (arthritis, diabetes, etc.)
Stress reduction
Other
Please tell us what you hope to gain with a personal trainer:
Knowledge of correct exercise
Techniques
Motivation
Goal-setting
Other
Structured programming
Do you prefer working with:
Male trainer
Female trainer
No preference
My available training times are:
5:30am - 9:00am
9:00am - Noon
Noon - 5:00pm
5:00pm - 8:00pm
Do you have any of the following health considerations:
Arthritis
Diabetes
High blood-pressure
Heart disease/previous heart attack
High cholesterol
Osteoporosis/osteopenia
Previous stroke
Fibromyalgia
Joint replacement(s)
Back injury/degeneration or chronic pain
Other
Referral Source
How did you first learn about CHF Personal Training?:
*
select...
Former PT participant
Daily Breeze
Easy Reader
Beach Reporter
Former Member
Referral - Friend or Family
Referral - Employee
Referral - Physician
Postcard or Mailer
LiveWell Mailer
www.BeachCitiesGym.com
Facebook or Twitter
Community Event
Handout or Signage at CHF
Silver Sneakers or Silver Slippers
Other
(If other, please explain below):
Program & Services
Yoga
Pilates
Group Exercise
Personal Training
Find a Trainer
Wellness & Meditation
Weight Management & Nutrition
Massage
65+ Programs
Polar Fitness Assessments
