New client intake form 2018-05-18T09:48:21+00:00

New client intake form

Please complete the confidential form below. We’ll be in touch right away to set up a complimentary, 60-minute consultation with you.

Your name

Your email

Cell phone

Home phone

Preferred contact method

Address



How did you hear about us? / Referred by


 

Personal information

 

Height

Weight

Gender

Age

Date of birth

Occupation

Hours worked per week

Hours of sleep per night

Current stress level (1 is low, 10 is high)

Hours of exercise per week

Top three fitness goals


 

Health history

 

Have you ever been diagnosed with coronary artery disease?

yesno
 

Have you ever been diagnosed with heart trouble?

yesno
 

Do you ever have bouts of dizziness?

yesno
 

Are you pregnant?

yesno
 

Have you ever had chest, arm, neck or shoulder pain after exercising?

yesno
 

Have you ever fainted after exercising?

yesno
 

Have you been diagnosed with high or low blood pressure?

yesno
 

Have you been diagnosed with high cholesterol?

yesno
 

Have you been diagnosed with joint or back issues?

yesno
 

Current injuries

Injury history

Have you had any surgeries? If yes, please list

What medications are you currently taking?

Date of your last physical exam

Additional comments or relevant information