New Client Intake Form

  • New Client Intake Form

    Please fill this out to the best of your ability. If you have any questions, please let us know. Thank you!
  • Format: (000) 000-0000.
  • Are you currently exercising?*
  • Do you smoke?*
  • Do you have a heart condition?*
  • Do you have a lung condition?*
  • Do you have back pain?*
  • Do you have high blood pressure?*
  • Do you have arthritis?*
  • Do you have osteopenia or osteoperosis?*
  • Do you have a physician's permission/are you cleared to participate in an exercise program?*
  • Do you have any current injuries?*
  • Do you have any pain?*
  • Do you have ADD/ADHD?*
  • Do you have hearing limitations?*
  • Do you have vision limitations?*
  • Are you currently under a physicians care?*
  • Do you take any medications?*
  • Should be Empty: