New Client Intake Form Play Pause Unmute Mute Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact *FirstLastPhone *What are your health goals?Shape (Lose Weight & Shape)Vitality (Energy & Health)Performance (Sports & Athletics)Rehab (Physical Therapy & Rehabilitation)Power (Strength & Definition)OtherChoose all that applyWhat are the biggest challenges to reaching your goals?FinancialScheduleMotivationOtherChoose all that applyIn the past, what techniques, diets, behaviors, etc, have you tried to reach your goals?History of heart problems, chest pain or stroke? *YesNoElevated blood pressure? *YesNoAny chronic illness or condition? *YesNoDifficulty with physical exercise? *YesNoAdvice from doctor not to exercise? *YesNoRecent surgery (last 12 months)? *YesNoHistory of breathing issues or lung problems? *YesNoMuscle, joint or back disorder or any previous injury still affecting you? *YesNoDiabetes or metabolic syndrome? *YesNoThyroid condition? *YesNoCancer? *YesNoUse of tobacco? *YesNoHistory of heart problems in immediate family? *YesNoHernia or any other condition that might be affected by lifting weights or other physical activity? *YesNoPlease 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:NameLet's Go!