New Client Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Date Of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### What are your health goals? * Choose all that apply Shape (Lose Weight & Shape) Vitality (Energy & Health) Performance (Sports & Athletics) Rehab (Physical Therapy & Rehabilitation) Power (Strength & Definition) Other What are the biggest challenges to reaching your goals? * Choose all that apply Financial Schedule Motivation Other In the past, what techniques, diets, behaviors, etc, have you tried to reach your goals? History of heart problems, chest pain or stroke? * No Yes Elevated blood pressure? * No Yes Any chronic illness or condition? * No Yes Difficulty with physical exercise? * No Yes Advice from doctor not to exercise? * No Yes Recent surgery (last 12 months)? * No Yes History of breathing issues or lung problems? * No Yes Muscle, joint or back disorder or any previous injury still affecting you? * No Yes Diabetes or metabolic syndrome? * No Yes Thyroid condition? * No Yes Cancer? * No Yes Use of tobacco? * No Yes History of heart problems in immediate family? * No Yes Hernia or any other condition that might be affected by lifting weights or other physical activity? * No Yes Please list all medications and/or supplements you currently take: Do you follow any special diet program or have diet restrictions or limitations for any reason? Please Explain: Thank you!
