Emerge Fitness New Client Forms
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Email *
First Name *
Last Name *
Date of Birth
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Address *
Email  *
Phone Number *
Physician Name & Phone Number  *
Occupation  *
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?  *
If yes, please describe below: 
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (ie diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, eating disorder, epilepsy, respiratory issues, back problems, ect) ? *
If yes, please describe below: 
Are you pregnant, breastfeeding or have you given birth in the last 6 months? *
Have you had a recent surgery?  *
If yes, please describe below: 
Do you take medications either prescription or non prescription on a regular basis? Please list medications and what they are used for below:  *
Do you smoke? *
Do you drink alcohol?  *
How Many Hours a night do you sleep? *
Does your job require travel?  *
On a scale of 1 to 10 how would you rate your stress level? *
List your biggest sources of stress:  *
Is anyone in your family overweight? *
Fitness & Exercise Related Questions: 
Have you been exercising regularly for the past 3 months?  *
On a scale of 1 to 10 how would you rate your current fitness level?  *
Worst
Best
When were you in the best shape of your life?  *
How often do you take part in physical exercise?  *
If your participation is lower than you would like it to be, what are the reasons?  *
Required
What activities are you currently involved in? *
How long have you been consistently active?  *
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