Name
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First Name
Last Name
What is your age?
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Are you regularly active in sports and/or exercise? If so, approximately how many hours per week?
What type of sport or activity do you do? If not applicable, write N/A.
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How physically active would you consider yourself, outside of exercise? Physical activity can include housework, walking to school or work, home repairs, moving around at work, etc.
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On a scale of 1-5, how would you rate your health in general right now?
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Given all the demands of your life, what is your typical stress level on average?
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On average, how many hours per night do you sleep?
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Do you currently have or have you had any of the following? Please check all that apply.
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Please provide more detail on the items checked above, if applicable.
Are you getting a normal period?
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Do you currently take any medications? If so, what and at what dose?
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Do you currently take over-the-counter supplements? If so, what and at what dose?
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Have you been hospitalized or had surgery within the last 5 years?
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Are you abiding by any particular dietary protocol?
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Are you interested in receiving guidance on proper nutrition throughout your membership with us?
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Do you make a conscientious effort to include protein in your diet?
Yes!
No.
Are there any health concerns we have not asked about OR has a doctor ever told you that you should not participate in exercise for any reason? If so, please tell us about these concerns.
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I understand that there are inherent risks involved in participating in an exercise program. I agree that all of the above is true to the best of my knowledge and my physician has cleared me for participating in an exercise program.
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Please type your name below to electronically certify this form.
