Language
English (US)
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General Client Information
Client Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Gender
*
Please Select
Male
Female
Other/Self Identifying
Client Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Client Weight (kg's)
*
Client Height (cm's)
*
Do you prefer In Person or Virtual Classes
*
Please Select
In person
Virtual
Hybrid (In person & Virtual)
Client Medical History
Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Epilepsy Seizures
Fainting Spells
Heart Disease
Heart Attack
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
COPD
Other illnesses:
Please list any major orthopedic injuries or operations (include dates)
List any body areas with pain
Include other important comments regarding your medical history
Healthy & Unhealthy Habits
Exercise
Never
1-2 days
3-4 days
5+ days
How many days a week would you like to exercise (If you purchased monthly plan)
2 days/week
3 days/week
4 days/week
5 days/week
Eating Habits (check all the apply)
I have a loose diet
I have a strict diet
I don't have a diet plan
Vegetartian
Pescatarian
Gluten Allergies
Alcohol Consumption
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
What are your personal health goals?
What are your overall goals? (Check all that apply)
Weight loss
Weight gain
Muscle toning
Strenghening
Competition training
Overall better health
Postnatal weight management
Improved self esteem/self motivation
Improve health due to medical issues
Minimize pain
What areas would you like to target? (Check all that apply)
Core/ abdomen
Legs
Arms
Back
Glutes
Submit
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