Fight 2B Fit DC Fitness Program Intake & Agreement
Please fill this out and submit prior to your assessment.
Email address *
Name *
First and last name
Your answer
Birthdate *
MM
/
DD
/
YYYY
Occupation; Lots of sitting? *
Your answer
Phone number *
Your answer
Emergency Contact: Name & Phone *
Your answer
Health Conditions *
Required
Do you smoke? *
Do you drink? *
How many drinks do you consume per week? *
Please describe and list any Injuries or conditions (other than what is mentioned above). Please include date, treatment and current status of the injury and/or condition. Please answer N/A if this does not apply to you. *
Your answer
Surgery in the last three months? If yes, please explain. *
Your answer
Describe any medical attention you are currently receiving for any injuries and/or condition. Please answer N/A if this does not apply to you. *
Your answer
Currently on any medications? *
Which medications? What for? Relevant side effects? Please answer N/A if this does not apply to you. *
Your answer
Level of Overall Physical Pain *
Specific locations of current pain. Please answer N/A if this does not apply to you. *
Your answer
Explain any discomfort or anxiety from any kind of activity. Please answer N/A if this does not apply to you. *
Your answer
What activities do you currently engage in? Sports? Lifting? Gardening? Leisure walking? Running? Group Exercise classes? Etc. Please describe. *
Your answer
How much time a week do you spend being active? *
How much sleep do you get each night? *
Level of Stress *
Describe your current diet. *
Your answer
List your top three goals. *
Your answer
Any obstacles in achieving your goals? *
Your answer
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