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Medical History Intake Form (Short Form)

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Thank you for your response. ✨

Name(required)

Email(required)

Phone Number(required)

Date of Birth (YYYY-MM-DD)

Indicate any medical conditions that may affect your ability to exercise safely.(required)

List any surgeries you have had.(required)

Are you currently taking any medications? If yes, please specify.(required)

Are you experiencing any pain or discomfort? If yes, please indicate the areas (check all that apply):(required)

Headaches Neck Pain Shoulder Pain Upper Back Pain Lower Back Pain Hip Pain Knee Pain Ankle or Foot Pain Wrist or Hand Pain Muscle Soreness

Please select the option that best describes your current level of physical activity:(required)

Sedentary (little or no exercise)

Lightly Active (light exercise 1–3 days/week)

Moderately Active (moderate exercise 3–5 days/week)

Very Active (hard exercise 6–7 days/week)

Extra Active (very hard exercise or physical job)

Briefly describe your prior experience with physical activity or exercise.(required)

What are your primary fitness goals? (Please select all that apply)(required)

Weight Loss Muscle Gain Improve Cardiovascular Fitness Increase Strength Enhance Flexibility Improve Posture Boost Energy Levels Stress Reduction Rehabilitation from Injury Prepare for a Specific Event (e.g. marathon, wedding) General Health and Wellness

I confirm that the information provided is accurate. I acknowledge that all information is confidential and will be used solely for your safety during training.

Medical History Intake Form (Short Form)

Thank you for your response. ✨

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