NEW MEMBER INTAKE FORM

Personal Information:
Name:_________________________________ Preferred Pronoun (he/she/they/etc): ___________________
Today’s Date:______________ Date of Birth:________________
Address:_________________________________________________________________________________
E-mail:____________________________________________ Phone Number: _________________________
Emergency Contact (Name and #):____________________________________________________________

Medical Health History:

How tall are you? _____________
What is your current weight? (optional) __________________
How would you describe your blood pressure? (circle one): High Normal Low
How would you describe your cholesterol level? (circle one): High Normal Low
Have you ever smoked cigarettes?: YES NO
If yes, for how long? _________________________________________________________________
Are you on any medications? YES NO
If yes, please explain:_________________________________________________________________
Do you have any allergies/Food allergies? YES NO
If yes, please explain:_________________________________________________________________
Has your physician ever said you have heart trouble? YES NO
If yes, please explain:_________________________________________________________________
Do you have a family history of any of the following?
Heart Disease: YES NO
High Blood Pressure: YES NO
Diabetes: YES NO
Asthma: YES NO
Do you often feel faint or experience spells of severe dizziness? YES NO
If yes, please explain:_________________________________________________________________
Has your physician ever told you that you have any joint or bone problems such as arthritis? YES NO
If yes, please explain:_________________________________________________________________
Have you been hospitalized recently for any cause? YES NO
If yes, please explain:_________________________________________________________________
Have you been in any recent car accidents? YES NO
If yes, please explain:_________________________________________________________________
Have you had any recent pregnancies? YES NO
If yes, please explain:_________________________________________________________________
 NEW MEMBER INTAKE FORM
How did you hear about us?_________________________________________________________________
Are you regularly active in sports or exercise? If yes what kind and how often? ________________________
Are you working out anywhere currently? Belong to a gym? YES NO
If yes, where?_______________________________________________________________________
Why are you looking for something different?______________________________________________
________________________________________________________________________________________
What do you hope to gain from more intensive coaching:___________________________________________
________________________________________________________________________________________
What workout programs, styles, classes, gyms, types of exercise have you tried in the past?
What worked well? __________________________________________________________________
________________________________________________________________________________________
What didn’t work well?________________________________________________________________
Do you have any interest in changing your diet or learning more information related to healthy eating habits?
[If yes then proceed to ask more about diet, if not, move on] YES NO
Are you currently following any particular diet or style of eating? YES NO
If yes, what? And for how long have you been eating this way?________________________________
________________________________________________________________________________________
Do you have any known/diagnosed food allergies or intolerances? YES NO
If yes, what are those?________________________________________________________________

Right now, how would you rank your habits in the following categories:

PHYSICAL FITNESS
HORRIBLE 1 2 3 4 5 6 7 8 9 10 AWESOME!

WHY?___________________________________________________________________________________________

EATING
HORRIBLE 1 2 3 4 5 6 7 8 9 10 AWESOME!

WHY?___________________________________________________________________________________________

RECOVERY (stress management, sleep, etc.)

HORRIBLE 1 2 3 4 5 6 7 8 9 10 AWESOME!

WHY?___________________________________________________________________________________________

MINDSET
HORRIBLE 1 2 3 4 5 6 7 8 9 10 AWESOME!

WHY?___________________________________________________________________________________________
 NEW MEMBER INTAKE FORM
LIFE OUTSIDE OF THE GYM?
What is your living situation? (spouse, partner, children, roommates, pets, etc?)
________________________________________________________________________________________
Do you have any children? YES NO
If yes, how many and what are their ages?________________________________________________
How do the external factors in your life help or hinder a healthy life style? (Ex: Work schedule, environment
you’re in, people in your life, schedule you keep?) ________________________________________________
_________________________________________________________________________________________________________________________

What is your occupation?____________________________________________________________________

On average how many hours per day do you spend at work and/or school? ____________________________
On average, how many hours per night do you sleep? _____________________________________________
Given the demands of your life, what is your typical stress level on an average day?
NO STRESS 1 2 3 4 5 6 7 8 9 10 EXTREME

How do you normally cope with stress? ________________________________________________________

________________________________________________________________________________________

DO YOU HAVE ANY PAIN OR INJURIES?

Describe any current aches, pains, or injuries you are experiencing:__________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Describe any past injures you have incurred:____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Is there anything else we should know about you that we haven’t yet discussed?________________________
________________________________________________________________________________________
________________________________________________________________________________________