GymRx Client Intake Form

Section 1: Client Information

Date:

Client Name:

Date of Birth:

Email:

Phone:

Time Zone:

Emergency Contact:

Emergency Contact Phone:

Relationship to Emergency Contact:

Primary Care Physician:

Primary Care Physician Phone:

Contract Selection & Payment Information

3-Month Contract
Standard pricing - $997

6-Month Contract
10% Discount Applied - $1,795

12-Month Contract
20% Discount Applied - $3,192

Agreed Upon Payment Rate: $

Payment Collection: Payment will be collected via secure link directing to www.gymrx.io

Client Initials:

Section 2: Virtual Training Environment Assessment

Technology Requirements & Setup

Device Type:

Computer

Tablet

Phone

Video Platform Experience:

Experienced

Moderate

Beginner

Training Space:

Home Gym

Commercial Gym

Outdoor Space

Other:

Flooring Type:

Carpet

Hardwood

Rubber Matting

Concrete

Other:

Equipment Availability Assessment

Environmental Safety Check: (ALL ITEMS REQUIRED)

Area is clear of obstacles and breakable items *REQUIRED*

Adequate lighting for video visibility *REQUIRED*

Stable internet connection confirmed *REQUIRED*

No pets/children will interrupt sessions *REQUIRED*

Emergency phone access available during sessions *REQUIRED*

Client Initials:

Section 3: Physical Activity Readiness Questionnaire (PAR-Q+)

This section helps determine if you need medical clearance before beginning online exercise

Has your doctor ever said that you have a heart condition OR high blood pressure?

YES

NO

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

YES

NO

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?

YES

NO

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

YES

NO

Are you currently taking prescribed medications for a chronic medical condition?

YES

NO

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue problem that could be made worse by becoming more physically active?

YES

NO

Has your doctor ever said that you should only do medically supervised physical activity?

YES

NO

Client Initials:

Section 4: Detailed Health History

Medical Conditions (Check all that apply)

Other Medical Conditions

Medications & Supplements

List all current medications that may affect exercise response:

Injuries & Surgeries

Past injuries affecting exercise:

Previous surgeries (with dates):

Family Medical History

Heart Disease:

Yes

No

Diabetes:

Yes

No

High Blood Pressure:

Yes

No

Client Initials:

Section 5: Fitness & Nutrition History

Exercise Experience

Current Activity Level:

Sedentary (little to no exercise)

Light Activity (1-3 days/week)

Moderate Activity (3-5 days/week)

High Activity (6-7 days/week)

Athlete (multiple sessions daily)

Years of Exercise Experience:

Beginner (0-1 years)

Intermediate (1-3 years)

Advanced (3+ years)

Previous Training Programs

Describe previous training programs or approaches you've tried:

Nutrition History

Previous Diet/Nutrition Programs:

Ketogenic Diet

Paleo Diet

Intermittent Fasting

Low Carb

Vegetarian

Vegan

Weight Watchers

None

Other:

Eating Habits & Preferences

Describe your current eating habits and food preferences:

How many meals do you typically eat per day?

1-2 meals

3 meals

4-5 meals

6+ meals

Water intake per day:

Less than 4 glasses

4-6 glasses

6-8 glasses

More than 8 glasses

Section 6: Goals & Expectations

Primary Goals (Rank your top 3 goals)

Instructions: Click on the goals below to select your top 3 most important goals. They will be automatically ranked as 1st, 2nd, and 3rd priority based on the order you select them.

Weight Loss

Muscle Gain

Strength Gain

Improve Cardiovascular Endurance

Improve Flexibility/Mobility

Increase Energy Levels

Stress Management

General Health & Wellness

Sport-Specific Performance

Specific Goal Details

Describe your specific goals and timeline:

Current Stats & Target Goals

Current Weight: lbs

Target Weight: lbs

Height:

Training Preferences

Preferred Session Length:

30 minutes

45 minutes

60 minutes

90 minutes

Preferred Training Frequency:

1-2 times per week

3-4 times per week

5-6 times per week

Daily

Preferred Training Time:

Early Morning (5-7 AM)

Morning (7-10 AM)

Midday (10 AM-2 PM)

Afternoon (2-6 PM)

Evening (6-9 PM)

Motivation & Challenges

What motivates you to exercise and maintain a healthy lifestyle?

What are your biggest challenges or obstacles to reaching your goals?

Client Initials:

Section 7: Lifestyle & Schedule

Daily Schedule

Occupation:

Work Schedule:

Traditional 9-5

Shift Work

Flexible Hours

Part-time

Unemployed/Retired

Stress Level (1-10):

Sleep Hours per Night:

Lifestyle Factors

I smoke tobacco

I consume alcohol regularly

I consume caffeine daily

I travel frequently for work

I have young children at home

I am a caregiver for family members

Support System

Support from family/friends for your fitness goals:

Very Supportive

Somewhat Supportive

Neutral

Unsupportive

Client Initials:

Section 8: Liability Waiver & Legal Agreement

VIRTUAL FITNESS TRAINING LIABILITY WAIVER AND RELEASE

ASSUMPTION OF RISK: I understand that participating in virtual fitness training sessions involves inherent risks including, but not limited to, the risk of injury, disability, or death. I voluntarily assume all risks associated with participating in virtual fitness training, including risks that may arise from my own negligence or the negligence of others.

RELEASE OF LIABILITY: In consideration for being permitted to participate in virtual fitness training sessions provided by GymRx, I hereby release, waive, discharge, and covenant not to sue GymRx, its owners, employees, agents, and representatives from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by me while participating in virtual fitness training.

MEDICAL CLEARANCE: I represent and warrant that I am physically fit and have no medical condition that would prevent my participation in virtual fitness training. I have consulted with a physician regarding my participation in this fitness program and have been cleared for physical activity.

INDEPENDENT JUDGMENT: I understand that I am responsible for monitoring my own condition throughout any virtual training session and will immediately discontinue participation if I feel any discomfort, pain, or other symptoms. I will exercise my own independent judgment regarding my ability to safely perform any recommended exercises.

EQUIPMENT AND ENVIRONMENT: I acknowledge that I am responsible for ensuring that my training environment is safe and that all equipment I use is in good working condition. GymRx is not responsible for any injury resulting from defective equipment or unsafe training environments.

NUTRITIONAL GUIDANCE: I understand that any nutritional guidance provided is for educational purposes only and is not intended to replace professional medical advice. I will consult with my healthcare provider before making significant dietary changes.

PRIVACY AND CONFIDENTIALITY: I understand that virtual training sessions may be recorded for quality assurance and training purposes. I consent to such recording and understand that my personal information will be kept confidential in accordance with applicable privacy laws.

CANCELLATION POLICY: I understand the cancellation and rescheduling policies for virtual training sessions and agree to provide adequate notice for any changes to scheduled appointments.

PROGRAM MODIFICATIONS: I understand that my training program may be modified based on my progress, feedback, and changing needs. I agree to communicate openly about my experience and any concerns that arise.

Acknowledgment and Agreement

I have read and fully understand this waiver and release of liability

I am participating voluntarily and understand the risks involved

I confirm that I have medical clearance to participate in physical exercise

I agree to the terms and conditions outlined in this document

I certify that all information provided in this form is accurate and complete

I am 18 years of age or older

Client Initials:

Section 9: Client Tracking & Check-in Requirements

MANDATORY TRACKING COMMITMENTS
By signing this agreement, I understand and agree to the following tracking requirements which are essential for program success:

Daily Tracking Requirements

I agree to track my daily caloric intake using the approved tracking method/app specified by my coach

I agree to track all exercise sessions and progress including weights, sets, reps, duration, and subjective feedback

I agree to track my daily/weekly weight and/or body composition measurements as specified in my program

Weekly Requirements

I agree to weigh in weekly on the same day of the week, at the same time of day, under consistent conditions

I understand that all tracking data must be completed and available for review during my weekly check-in

Weekly Check-in Policy

Scheduling & Attendance:

Weekly check-ins will occur on the agreed-upon day and time:

Check-in duration: 30 minutes (unless otherwise specified)
Check-ins cannot be modified or rescheduled with less than 24 hours advance notice
Failure to provide 24-hour notice will result in forfeiture of that week's check-in session

Check-In Requirements:

During each weekly check-in, the following items must be completed and reviewed:

Caloric intake tracking review - complete food logs from the previous week
Exercise progress review - all workout data and performance metrics
Weight/body composition review - weekly measurements and progress photos (if applicable)
Program adjustments - modifications based on progress and feedback
Goal assessment - evaluation of progress toward established objectives

Missed Check-In Policy:

Missed check-ins without 24-hour notice: Session forfeited, no makeup provided
Client-initiated cancellations with proper notice: One makeup session per month allowed
Consecutive missed check-ins may result in program suspension pending discussion

Data Submission Requirements:

All tracking data must be submitted 24 hours prior to scheduled check-in
Incomplete tracking data may result in abbreviated check-in session
Consistent failure to maintain tracking requirements may result in program termination

Client Initials:

Section 10: Payment Policy

Payment Terms

All payments are due in full upon contract signing
All payments are NON-REFUNDABLE regardless of reason for discontinuation
Payment processing fees (if applicable) are the responsibility of the client

Non-Refund Policy

I understand and agree that:

No refunds will be provided for any reason including but not limited to:

Personal schedule changes or time constraints
Dissatisfaction with program or results
Medical issues or injury (unless program is medically contraindicated)
Technology issues or platform changes
Change in financial circumstances
Relocation or travel commitments

Additional Coaching Services

Supplemental Sessions:

Additional coaching sessions beyond the contracted weekly check-ins are available as needed
Rate for additional sessions: $150 per hour
Additional sessions must be scheduled in advance and are subject to trainer availability
Payment for additional sessions is due at time of booking
Additional sessions follow the same 24-hour cancellation policy

What constitutes additional coaching:

Extra check-in sessions beyond weekly requirement
Extended sessions exceeding standard 30-minute duration
Emergency coaching calls or consultations
Additional meal planning or program design requests
In-depth progress assessments beyond standard check-ins

Client Initials:

Section 11: Progress Photos & Testimonial Consent Agreement

Progress Photo Requirements & Consent

Monthly Progress Photo Commitment:

I agree to provide progress photos on at least a monthly basis throughout the duration of my coaching program

I understand that photos must be taken in the same environment and lighting conditions for consistency and accurate progress tracking

I agree to follow the specific photo guidelines provided by my coach regarding poses, clothing, and timing

Photo Specifications

Frequency: Minimum monthly (may be requested more frequently based on program needs)
Environment: Same location, lighting, and background for all photos
Poses: Front, side, and back views (or as specified by coach)
Clothing: Consistent minimal clothing to accurately assess body composition changes
Timing: Photos taken at the same time of day under similar conditions

Testimonial Agreement

Post-Program Testimonial Commitment:

I agree to write a testimonial regarding my experience with Dr. Dave and GymRx following completion of my coaching program

I understand this testimonial will include my honest assessment of the program, results achieved, and overall experience

Required Testimonial Information

The testimonial will contain the following information:

First name and last initial (full name may be omitted for privacy)
Occupation of the client
Estimated number of hours per week spent on occupation
Program results and experience details
Any relevant before/after metrics or achievements

Marketing & Publication Rights

Consent to Use for Marketing Purposes:

I grant GymRx LLC and Dr. Dave full rights to use my progress photos and testimonial for marketing, advertising, and promotional purposes

I understand these materials may be used in the following ways:

GymRx website and social media platforms

Marketing materials and advertisements

Affiliated publications and partner websites

Promotional videos or presentations

Print materials and brochures

Any other marketing or educational purposes

Rights Waiver & Internet Permanence Acknowledgment

By signing this document, I acknowledge and agree that:

I waive all rights to the publication of my progress photos and testimonial
I understand that due to the nature of the internet, it may not be possible to revoke or remove these items once published
I consent to the perpetual use of these materials without additional compensation
I understand that these materials may be shared, reposted, or republished by third parties beyond GymRx's control
I release GymRx LLC and Dr. Dave from any claims related to the use of my likeness, photos, or testimonial content

Privacy Options

I consent to use of my full name in testimonials and marketing materials

I prefer to use only first name and last initial for privacy purposes

I consent to the use of my age and occupation in marketing materials and testimonials

Client Initials:

Section 12: Virtual Training Agreement & Policies

Technology Requirements

Minimum Requirements:

High-speed internet (minimum 25 Mbps recommended)
Device with camera and microphone capabilities
Updated web browser or app platform
Quiet, private space for training sessions

Session Policies

Scheduling:

Sessions must be scheduled 24 hours in advance
Cancellations require 24-hour notice
No-shows result in full session charge
Technology issues requiring session restart count as attended

Refund Policy for Virtual Services

Technology-Related Issues:

Trainer technology failures: Full refund/makeup session
Client technology issues: No refund (counts as attended)
Platform outages: Makeup session provided

Client Initials:

Section 13: Scope of Practice & Virtual Limitations

Professional Boundaries for Online Training

Services Provided:

Nutrition education and meal planning guidance
Dietary analysis and nutritional assessments
General wellness and nutrition education
Motivational coaching and accountability

Services NOT Provided:

Medical diagnosis or treatment
Clinical nutrition therapy or medical nutrition therapy
Prescription of specific supplements or medications
Treatment of diagnosed medical conditions or eating disorders

Virtual Training Limitations Acknowledgment

I understand that virtual training cannot provide:

Physical spotting or hands-on assistance
Immediate emergency medical response
Direct equipment safety monitoring
In-person form correction and adjustment

Client Initials:

Section 14: Final Acknowledgments for Virtual Training

Client Acknowledgment

By signing below, I acknowledge that:

I have read and understand all sections specific to virtual training

I understand the enhanced risks and limitations of online training

I have assessed my training environment for safety

I accept responsibility for my exercise environment and equipment

I understand technology limitations may affect training quality

I voluntarily assume all risks of virtual training participation

I release all parties from liability related to online training

I understand this agreement applies to all virtual nutrition services

I am at least 18 years of age

Client Final Signature

Print Name:

Client Signature:

Date:

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