Client Information

Client information:

* Indicates required field

Status: *

Miss Mr. Mrs. Ms.

Name *

First

Last

Date of Birth (mm/dd/yyyy) *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Medications:

Are you currently taking any medications? *

Yes No

If you checked YES, please list the medication and for what condition:

1. Medication *

1. Condition *

2. Medication *

2. Condition *

3. Medication *

3. Condition *

For women only:

1. Are you pregnant? *

Yes No

If yes, then

How many months? *

Approx. date of delivery *

2. Have you been told to restrict your activities during pregnancy? *

Yes No

3. How many pregnancies have you had? *

4. Would you consider them normal? *

Yes No

5. Did you exercise during pregnancy? *

Yes No

6. Date of last pregnancy: *

7. Was it full term? *

Yes No

Injuries

Current Activity Levels

Lifestyle

3. Do you smoke? *

Yes No

4. What is your alcohol consumption? *

None Mild Moderate Frequent

nutritional habits

1. Do you follow a special diet? *

Yes No

2. How would you rate your eating habits? *

Poor Ok Good Very Good

3. Is weight loss one of your primary exercise goals? *

Yes No

4. What are your other fitness goals? *

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