Full Name:

Phone:

Email:

DOB:

Address:

Weight(lbs):

Height(inches):

Referral:

Emergency Contact Name:

Relationship:

Emergency Contact Phone:

What are your fitness goals?

How many days would you like to train per week?

Best dates to workout?

Where do you want to train?

Any additional information you would like to add?

1) Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

2) Do you feel pain in your chest when you perform physical activity?

3) In the past month, have you had chest pain when you were not performing any physical activity?

4) Do you lose your balance because of dizziness or do you ever lose consciousness?

5) Do you have a bone or joint problem that could be made worse by a change in your physical activity?

6) Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

7) Do you know of any other reason why you should not engage in physical activity?

8) Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)

9) Have you ever had any surgeries? (If yes, please explain.)

10) Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)

11) Are you currently taking any medication? (If yes, please list.)