Re6el Fit Client Questionnaire
Please complete this form before scheduling your workout session.
Name *
Phone number *
Today's Date *
MM
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DD
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Your Physicians Name & Number (in case of an emergency)
Emergency Contact Name & Number *
Are you taking any medications, supplements, etc? If so please list medication and dose, along with reason. *
Does your physician suggest in participating in exercising program? *
Describe any physical activity you do and how often: *
Please check all that apply to you currently:
If you read, agree and understand the consent terms found at: www.re6elfit.com/consent, please type your full name below. This will be considered your electronic signature. *
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