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

    Preferred pronouns

    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