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Fitness Intake Form
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Contact Information
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First Name
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Your answer
Last Name
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Your answer
Address
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Full mailing address
Your answer
Email
*
Your answer
Cell Phone #
*
Your answer
Gender
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Female
Male
Other:
Birthday
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MM
/
DD
/
YYYY
Referred by:
Your answer
How did you hear about us?
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Facebook
Instagram
Email Newsletter
Bootcamp
Other:
Occupation
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Your answer
Emergency Contact
*
Your answer
Emergency Contact Relationship
*
Your answer
Emergency Contact Phone
*
Your answer
Lifestyle Information
What is your height?
*
Your answer
What is your weight?
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Your answer
What is your desired weight?
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Your answer
What is your highest adult weight and when was it?
*
Your answer
What was your weight one year ago?
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Your answer
What is (are) your immediate fitness goal(s)?
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Your answer
The biggest challenges to reaching my fitness goals are:
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Your answer
How many days per week do you consistently participate in vigorous exercise?
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None
1-2
3-4
5-6
Everyday
On average, how many hours of sleep do you get?
Your answer
Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious, or other)?
Your answer
How many days per week do you consume alcohol?
Never
1-2 days per week
3-4 days per week
5-6 days per week
Nightly
Clear selection
Indicate daily stressors and rate the level of stress from 1 to 10
Work
*
extremely low
1
2
3
4
5
6
7
8
9
10
extremely high
Family
*
extremely low
1
2
3
4
5
6
7
8
9
10
extremely high
Social
*
extremely low
1
2
3
4
5
6
7
8
9
10
extremely high
Financial
*
extremely low
1
2
3
4
5
6
7
8
9
10
extremely high
Health
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extremely low
1
2
3
4
5
6
7
8
9
10
extremely high
Medical Information
Are you taking any medications?
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Yes
No
If yes, please list name and use:
Your answer
Are you currently pregnant?
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Yes
No
If so, how far along?
Your answer
Any high risk factors?
Your answer
Do you suffer from chronic pain?
*
Yes
No
If yes, please explain:
Your answer
What makes it better?
Your answer
What makes it worse?
Your answer
Have you had any orthopedic injuries?
*
Yes
No
If yes, please list:
Your answer
Please indicate any of the following that apply to you:
*
Cancer
Headaches/Migranes
Arthritis
Diabetes
Joint Replacement
High/Low Blood Pressure
Neurotherapy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
None of the above
Required
Explain any conditions you have marked above:
Your answer
Are there any other conditions that not listed above?
Your answer
Do you have any allergies or sensitivities?
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Yes
No
Not Sure
If yes, please explain:
Your answer
I agree to use electronic records and signatures
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Yes
I have read the Terms and Conditions
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FitStyle.com/terms-and-conditions
Yes
I have read the Privacy Policy
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FitStyle.com/privacy-policy
Yes
By signing below, I agree that all the information above is true.
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Type your full name as your electronic signature
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