Client History Form

Our Promise

Our Wellness Specialists promise to provide a professional and courteous experience in order assist in meeting your health and fitness goals.

Mission Statement

Our Wellness Specialists believe your wellness is the ability to balance your life. We help you make yourself a priority.

We are dedicated to assist you in balancing your health and fitness through a focused, safe and individualized program.

Completing the Client History Form offers our Wellness Specialists the most recent information about you and your family history. The more information we have about your physical health, the better and more comprehensive your program.

Please submit all of the following fields before submitting this form.

Describe any specific changes you’d like to make through your overall fitness program?

General Client Information


Name


First Name

Last Name


Primary Address

Street Address

City

State

Zip

Other Residence (if applicable)

Street Address

City

State

Zip

Home Phone

Telephone format must be (###)###-####

Mobile Phone

Telephone format must be (###)###-####

Work Phone

Telephone format must be (###)###-####

Occupation

Email

Website

Date of Birth

Age

Height

Weight

Pant Size

Shirt Size

Dress Size


Children
How many and names

Grandchildren
How many and names

Hobbies


Emergency Contact

Name

Phone


Date you can start training

Medical Information


Doctor’s Name

Phone

Fax


Address

Street Address

City

State

Zip Code

Referral Information


Who referred you to us?

How did you find us?

Health and Wellness Questionnaire


Current Fitness Habits

Strength Training

PoorFairGoodGreatExcellent

Cardio

PoorFairGoodGreatExcellent

Flexibility

PoorFairGoodGreatExcellent
Current Nutritional Habits

Overall Daily Diet

Very UnheatlthyUnhealthyAverageHealthyVery Healthy

Breakfast

Very UnheatlthyUnhealthyAverageHealthyVery Healthy

Lunch

Very UnheatlthyUnhealthyAverageHealthyVery Healthy

Dinner

Very UnheatlthyUnhealthyAverageHealthyVery Healthy

Snacks

Very UnheatlthyUnhealthyAverageHealthyVery Healthy
Barriers

Select all that apply

No TimeToo TiredUnsure where to startExercise hurts my joints/musclesI dislike exercise or find it boringToo many priorities (home, work, family, etc.)Work too much"Why bother"

I am interested in learning more about:


Strength Training Programs:

Not At AllSomewhat InterestedVery InterestedExtrememly Interested

Cardiovascular Programs:

Not At AllSomewhat InterestedVery InterestedExtrememly Interested

Flexibility Programs:

Not At AllSomewhat InterestedVery InterestedExtrememly Interested

Stress Management Programs

Not At AllSomewhat InterestedVery InterestedExtrememly Interested

What type of weight loss have you been involved with?


Diet

Year

Weight Lost

Weight Returned

Close Menu