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