Member Form

First name

Last name

Phone Number

Email address

Best Way to Contact You?

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Please select your reasons for joining our club (indicate all that apply):

Improve performanceAvoid or recover from injuryIncrease mobilityMaintain a healthy weightPromote/support active agingGain muscle/lean massLower A1C, Blood Sugar, Blood Pressure and/or CholesterolImprove nutrition (Yes, we can help with that!)

What, if any, specific goals do you have?

What are you looking to get out of your consultation(s)?

What, if any, roadblocks do you have that are limiting your ability to meet your goals?

Lack of timeSafety concernsStuck at plateauNeed guidanceBored with routineInjury

As a new member, I would like to:

...meet with a Doctor of Physical Therapy....do a Q&A with a Registered Dietitian....have a consultation with a Certified Personal Trainer (CPT).

Do you have a preference in the trainer you work with?

Is there anything else you would like to share with us?

When was the last time you had a physical examination?

List any medications you are taking, why and the dosage level if known.

Has your doctor ever diagnosed you as having one or more of the following:

Heart diseaseStrokeGERD (Heartburn)EpilepsyPre-diabetes or diabetesCrohn’s Disease or Ulcerative ColitisOsteopenia or OsteoporosisDisordered Eating or Eating Disorder

Any history of gut health issues (bloating, gas, constipation, etc) or food allergies/intolerances?

Females Only. Are you pregnant?

List any other medical problems that you may have.

Increased blood cholesterol (total>200mg/dl)?

High blood pressure (>120/80mg)?

History of breathing or lung problems?

Tobacco smoking habit?

Hernia or any condition that may be aggravated by lifting weights?

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

YesNo

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

YesNo

Do you have a bone or joint problem (for example; back, knee, or hip) that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

YesNo

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If you answered NO honestly to all questions, you can be reasonably sure that you can:
● Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
● Take part in a fitness appraisal; this is an excellent way to determine your basic fitness so that you can plan the best way to
live actively.
Please note: If your health changes so that you answer YES to any of the questions, tell your fitness or health professional. Ask
whether you should change your physical activity plan.

Entering your name in the above electronic signature indicates you acknowledge the information you have provided in the above form or waiver.