NEW CLIENT APPLICATION FORM
Infinite Strength & Rehabilitation
Client Name
First Name
Last Name
Preferred Name
Title
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Word of mouth
Google
Social Media
GP Clinic
Other
What are your short-term health & fitness goals?
What are your long-term health & fitness goals?
Where are you currently at with your health & fitness?
Do you have any medical conditions?
How much sleep do you get per day?
What is your daily nutrition like?
Are you a smoker?
Yes
No
Sometimes
What do you do for a living?
How often are you willing to commit to your health & fitness goals per week?
1-2 times per week
3-4 times per week
5-7 times per week
Other
What are you struggling with the most when it comes to reaching your health & fitness goals?
What options best suits you and your health & fitness needs?
General population (chronic pain management, occupational pain management, sarcopenia management, women's health)
Powerlifting
If you're coming to me for powerlifting, what option best suits you?
Beginner
Intermediate
Advanced
Other
How committed are you to working with me to reach your health & fitness goals?
1
2
3
4
5
Least
Most
1 is Least, 5 is Most
How much are you willing to spend per week to work with me?
Under $50
$100-$200
$200+
Thank you! If you qualify to work with me I will reach out to you within 48 hours. If you have any questions or comments for me please let me know below.
Submit
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