New Client Information

Address

Phone Number

Area Code Phone Number
Email
example@example.com
Referred by:
Emergency contact information:
Let us know more about your goals.
What is your primary fitness goal?
What are your secondary fitness goals?
When would you like to accomplish your goal(s) by?

Month Day Year
Date
Please provide information regarding any current or past injuries that may limit your training so that we can provide you an appropriate training program.
Have you ever been diagnosed with a heart condition?

yes no
Do you ever get dizzy when exercising or exerting high amounts of effort?

yes no
Has a Doctor ever diagnosed you with a medical condition that may be made worse by certain types of exercise?

yes no
Do you ever have pain in your chest when you perform physical activity?

yes no
Do you have a bone or joint problem that could be made worse by a change in physical activity?

yes no
Is your doctor, currently, prescribing any medication for your blood pressure or for a heart condition?

yes no
Please list any current or past injuries, surgeries and any medications that you may be taking.
If you have answered "yes" to any of the questions in the above section, consult your physician before engaging in physical activity. Tell your physician which questions you answered "yes" to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
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