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Fletcher Fitness New Client Form
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Email *
Name *
First & Last
Date Of Birth *
MM
/
DD
/
YYYY
Address, City, State, Zip Code *
Phone Number *
Emergency Contact *
Include First And Last Name, And Phone Number
Past Injuries *
Medical Restrictions *
Prescriptions/Medications *
Do you have chest pain brought on by physical activity? *
Have you ever been diagnosed with high/low blood pressure? *
Have you ever been diagnosed with diabetes? *
Have you ever been diagnosed with high cholesterol? *
Have you ever been diagnosed with any other medical condition? *
If you answered YES to "Have you ever been diagnosed with any other medical condition?" please list the medical conditions.
Have you consulted your physician regarding increasing your physical activity and or performing a physical assessment? *
Do you currently exercise? *
If you answered YES to "Do you currently exercise?" describe your exercise. Type, frequency, length of time, etc.
Have you previously been a member of a gym? *
Have you ever participated in a personal/small group training program? *
How did you hear about us?
If by referral then answer with the name of who referred you.
 *
What are your short term goals for exercise, health and fitness? *
What are your long term goals for exercise, health and fitness? *
How serious are you about reaching your goals?
VERY LOW
VERY HIGH
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