Welcome. Let's Build Your Foundation.

This intake form helps Jonathan understand your body, your history, and your life so he can build a program that's truly built for you. Be as detailed as you can — the more you share, the better your program will be.

This is confidential. Everything you share stays between you and Jonathan.

The basics.

Full Name*

Email Address*

Date of Birth

Home Address

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Primary Care Physician Name

Primary Care Physician Phone

Your body's story.

Do any of these apply to you? (Select all that apply)

Please describe your conditions in more detail (optional)

List any surgeries and approximate year

Current medications

Any allergies relevant to exercise?

Has a doctor ever advised you against exercise?

Currently being treated by any of the following? (Select all that apply)

How your body moves right now.

Areas that feel tight or restricted

Areas of chronic pain

Do you experience any of the following? (Select all that apply)

Have you fallen in the past two years?

Daily activities that feel harder than they used to

Physical activities you currently enjoy or want to be able to do

Your life outside sessions.

Typical weekday activity level

Hours of sleep per night

Sleep quality

PoorExcellent

Daily stress level

Very highVery low

Daily water intake

Current eating habits

Alcohol consumption

Tobacco use

Making this work for your life.

Where will sessions take place? (Select all that apply)

Equipment available at home

Best days and times for sessions

Preferred communication method

Have you used a fitness app before?

Comfort level with smartphone apps

Not comfortableVery comfortable

The mental side.

What motivates you most when it comes to your health and body?

What does physical capability mean to you personally?

What would being stronger and more capable in one year mean to you emotionally?

When you hit a physical challenge, how do you tend to respond?

Do you have support from a spouse or family for this commitment?

Last one.

The ONE thing you most want to change about how your body feels or functions*

Anything else Jonathan should know?

Jonathan will review this before your first session. If anything needs clarification he'll reach out directly. See you soon.