New client intake form

Please complete the confidential form below. Note that filling out this form is step #2 in our extensive client intake process. If you have not yet had an in person or phone conversation with Jeremy or Lee, let’s get that scheduled right away! Providing the most comprehensive insight into your health history and goals is an important part of creating a successful trainer/client relationship.

Your name

Your email

Cell phone

Home phone

Preferred contact method

Address



How did you hear about us? / Referred by


 

Personal health information

 

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