Information & Health History

This form is a complete profile of your personal contact information as well as current physical condition and goals you wish to achieve. We very much appreciate you taking the time complete this form as fully as possible.
MM slash DD slash YYYY
A copy of this form will be sent to this email address.
Date of Birth:(Required)
Have you ever retained a personal trainer or coach in the past?

EMERGENCY CONTACT:

HEALTH HISTORY:

Did you receive a medical clearance from your physician prior to beginning your exercise program?(Required)
Has your doctor ever advised you against exercise?(Required)
Have you undergone any surgeries in the past year?(Required)
Do you have any areas of your body that limit you during exercise?
Is this limitation constant or does it "come and go?"

PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING:

LONG TERM GOALS AND OBJECTIVES FOR YOU AND YOUR BODY:

Specific Body Areas: (ie; arms, legs, abs, glutes, etc.)