Client Profile

Client Profile

TAG Health & Fitness
Congratulations on your decision to start a heathier, happier and more productive life-style. This program is designed to enhance your health & fitness knowledge and obtain new and exciting goals. Your program will be designed specifically for you. You will reach goals you never thought possible! Many have succeeded with their programs and so can you. Please take a few minutes to complete the following. If you have any questions please contact me.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Best time to reach you
Height
Weight
Date of birth
Occupation
Weekly work hours
Number of Children
Best time to workout
List 3 goals you would like to reach with this program?
Are you on any medications?
Health History (please check all that apply)

High blood pressureSmokeElevated cholesterolHeart attackCardiac surgeryDiabetesHeart murmurVascular disorderAsthmaCOPDChest discomfortShortness of breathSwollen, stiff, painful jointsAny muscular or joint injuryPregnantDrink alcohol dailyOther
In the last 2 weeks have you been bothered by any of the following problems? (please check all that apply)

Feeling down, anxiety, or depressedTrouble sleepingLow to no energyPoor appetite or overeatingHard time concentratingOther
If yes to any of the questions above please explain:
Family History (please check all that apply)

Heart attackHigh blood pressureDiabetesStrokeCoronary diseaseCoronary operationsElevated lipid profilesCancerObesityOther
Tell me a little bit for about your journey, why have decided to make this change?
Should be Empty: