Fitness Intake Form
Contact Information
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First Name *
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Last Name *
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Address *
Full mailing address
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Email *
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Cell Phone # *
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Gender *
Birthday *
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Referred by:
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How did you hear about us? *
Occupation *
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Emergency Contact *
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Emergency Contact Relationship *
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Emergency Contact Phone *
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Lifestyle Information
What is your height? *
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What is your weight? *
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What is your desired weight? *
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What is your highest adult weight and when was it? *
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What was your weight one year ago? *
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What is (are) your immediate fitness goal(s)? *
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The biggest challenges to reaching my fitness goals are: *
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How many days per week do you consistently participate in vigorous exercise? *
On average, how many hours of sleep do you get?
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Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious, or other)?
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How many days per week do you consume alcohol?
Indicate daily stressors and rate the level of stress from 1 to 10
Work *
extremely low
extremely high
Family *
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extremely high
Social *
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Financial *
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Health *
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Medical Information
Are you taking any medications? *
If yes, please list name and use:
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Are you currently pregnant? *
If so, how far along?
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Any high risk factors?
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Do you suffer from chronic pain? *
If yes, please explain:
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What makes it better?
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What makes it worse?
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Have you had any orthopedic injuries? *
If yes, please list:
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Please indicate any of the following that apply to you: *
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Explain any conditions you have marked above:
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Are there any other conditions that not listed above?
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Do you have any allergies or sensitivities? *
If yes, please explain:
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I agree to use electronic records and signatures *
I have read the Terms and Conditions *
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I have read the Privacy Policy *
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By signing below, I agree that all the information above is true. *
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