General Health Information
Hoffacker Health and Fitness
Name
First Name
Last Name
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
-
Area Code
Phone Number
Home Number
-
Area Code
Phone Number
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
Date
Gender
Male
Female
Non-binary
Occupation
Emergency Contact
First Name
Last Name
Emergency Contact Number
-
Area Code
Phone Number
Relationship to you
Who is your appointed conditioning specialist?
Steve Hoffacker
Devin Riley
Emily Bryan
Lauren Paladin
Aaron Monson
Daniel Hursh
Alle Baker
Riley Miller
Kim Rose
Amanda Harness
RJ Dowdell
Not yet appointed
What equipment do you have readily available to use at home or health club facility?
Cardiovascular
Strength Conditioning
Stretching and Flexibility
Outdoor accessories (Bike, run, walk, climb, etc.)
What is your training preference?
At home
At one of the HHF conditioning facilities
Do you consider yourself
Sedentary (little, if any, vigorous activity)
Lightly Active (sporadic workout, little aerobic, lawn work)
Moderately Active (workout 1-2 days/wk for 15-20 min)
Highly Active (workout 3+ days/wk for 30-45 min)
Have you been injured or hospitalized in the last year?
Yes
No
If yes, what was the injury or reason for hospitalization?
What caused the injury or hospitalization?
Back
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Have you ever had any injury or disorders associated with the following body parts? (Check all that apply)
Bone
Joint
Muscle
Back
Please check any affected bones
Neck
Back
Ribs
Arm bones - Right
Arm bones - Left
Leg bones - Right
Leg bones - Left
Other
Please check any affected joints
Shoulder - Right
Shoulder - Left
Elbow - Right
Elbow - Left
Wrist - Right
Wrist - Left
Hand - Right
Hand - Left
Hip - Right
Hip - Left
Knee - Right
Knee - Left
Ankle - Right
Ankle - Left
Foot - Right
Foot - Left
Other
Please check any affected muscles
Neck
Back
Stomach
Arm - Right
Arm - Left
Leg - Right
Leg - Left
Other
Please check the affected back area
Neck
Upper back
Mid back
Lower back
Are you on any blood thinners / anti-coagulants?
Yes
No
If female, are you pregnant?
Yes
No
From how many doctors are you currently receiving care?
Physician Information #1:
First Name
Last Name
Specialization
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Information #2
First Name
Last Name
Specialization
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Save
Is there any pertinent information regarding your health history that has not already been described?
Yes
No
If yes, please explain:
What are your fitness goals?
Preferred Payment Option
Auto Pay - charge credit card on file
65th Street Kiosk (Swipe Credit Card)
Will make check or cash payment in advance of session
No Auto Pay - Get authorization before charging credit card on file
I don't know at this time
Taking part in a Corporate Account
Save
Submit
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