New Client Intake Form

Name *

First

Last

Email *

Phone *

Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact *

First

Last

Phone *

What are your health goals?

Choose all that apply

What are the biggest challenges to reaching your goals?

Financial
Schedule
Motivation
Other

Choose all that apply

In the past, what techniques, diets, behaviors, etc, have you tried to reach your goals?

History of heart problems, chest pain or stroke? *

Yes
No

Elevated blood pressure? *

Yes
No

Any chronic illness or condition? *

Yes
No

Difficulty with physical exercise? *

Yes
No

Advice from doctor not to exercise? *

Yes
No

Recent surgery (last 12 months)? *

Yes
No

History of breathing issues or lung problems? *

Yes
No

Muscle, joint or back disorder or any previous injury still affecting you? *

Yes
No

Diabetes or metabolic syndrome? *

Yes
No

Thyroid condition? *

Yes
No

Cancer? *

Yes
No

Use of tobacco? *

Yes
No

History of heart problems in immediate family? *

Yes
No

Hernia or any other condition that might be affected by lifting weights or other physical activity? *

Yes
No

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:

Don’t “Just” Breathe

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