New Client Intake

First Name

Last Name

Phone

Birthday

Address

Emergency Contact Name

Emergency Contact Phone

Please list your TOP 3 Fitness Goals:

How would you describe your activity levels during the day?

How many times a day do you usually eat?

Do you feel drops of energy throughout the day?

When were you in the best shape of your life?

On a scale of 1-10, how committed are you to achieving your fitness goals?

Have you ever been diagnosed with Heart Disease or Stroke? Any Medications?

Has a doctor said that you have high blood pressure? Medications?

Do you ever faint or lose consciousness as a result of dizziness?

Do you smoke? If yes, how much/often?

Do you have any bone or joint problems that could be aggravated by any type of physical activity? If yes, please describe:

Is there any reason, through your own experience or recommendation from a doctor that you should not participate in an exercise program without medical supervision?

If you have answered YES to any of the above questions, have you consulted your physicians regarding increasing your activity level or beginning an exercise program?

If necessary, will you consult a physician prior to participating in any type of exercise program?

I certify the above statements are true:

Your Signature

Today's Date:

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