New Client Intake Form

Peterson Training is pleased to provide a Free 50-minute consultation for new members! If you're considering training or have any questions, fill out the contact form first and we will be in touch as soon as possible.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about us? / Referred by

Personal Health Information

Gender

Age

Date of birth

YYYY

Occupation

Hours worked per week

Hours of sleep per night

Current stress level (1 is low, 10 is high)

Hours of exercise per week

Top three fitness goals

Health History

Have you ever been diagnosed with coronary artery disease?

Have you ever been diagnosed with heart trouble?

Do you ever have bouts of dizziness?

Are you pregnant?

Have you ever had chest, arm, neck or shoulder pain after exercising?

Have you ever fainted after exercising?

Have you been diagnosed with high or low blood pressure?

Have you been diagnosed with high cholesterol?

Have you been diagnosed with joint or back issues?

Current Injuries

Injury History

Have you had any surgeries? If yes, please explain

What medications are you currently taking?

Date of your last physical exam

YYYY

Additional comments or relevant information

New Client Intake Form

Lindsay Peterson