My Wellness Profile

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Name of Emergency Contact

Emergency Contact Phone

Do you have any medical conditions we should be aware of? If yes, please explain (include all such as high blood pressure, high cholesterol, blood sugar concerns etc..)

Do you take any medications on a regular basis? If yes, please explain what you take them for.

Do you have any current injuries? If yes, please explain

Have you had any surgeries in the past 5 years? If yes, please explain.

In the past year how often have you worked out?

Never

1-2 days/wk

3-4 days/wk

5+ days/wk

Have you worked out with a personal trainer before?

Yes

No

What are your top 3 fitness goals for the next 6 months?

Is there anything else you would like us to know?

Please review and sign our Client Agreement & Policies below -- by signing, you confirm that you have read and agree to the terms.

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Please review and sign our Client Agreement and Policies here.

By completing and submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge so we can best support your care.

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