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Stott Pilates
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Pilates Apprentice
Gyrotonic®
Drop In Classes
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ENERGY SPACE ®
Fascia Conditioning Class
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Client Forms
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Rentals
Contact/ Inquiry Form
About
Trainers
Staff
Personal Training
Pilates
Classes
Stott Pilates
Pilates Rentals
Apply to Join the Team
Pilates Apprentice
Gyrotonic®
Drop In Classes
Group Classes
Pop Up Classes
1 Minute Exercises
Special Services
ENERGY SPACE ®
Fascia Conditioning Class
Yoga and Meditation
Silver&Fit Partnership
Wellness at Work
Massage Therapy
Events
Upcoming Events
GTSTLC Events
FAQ
Updates During COVID-19
New Client Specials
Client Forms
Fees
Gift Cards
Rentals
Contact/ Inquiry Form
MEDICAL HISTORY/ PERSONAL FITNESS GOALS
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Date of Birth
MM
DD
YYYY
Emergency Contact Person
First Name
Last Name
Check here if you are a member of ASH (American Specialty Health).
Yes, I am a member of ASH.
Physician Name
First Name
Last Name
Physician Phone #
(###)
###
####
Medications currently being used (please list all):
Do you currently take any supplements?
Please describe what you would like to achieve with personal training (e.g., weight loss or weight management, general health and wellness, “feel better”, sport training, or to address specific health concerns, etc.)
What is your current occupation?
How much physical activity do you perform while on the job?
*
Please select from drop down options.
Very Little
Little
Moderate
Active
Very Active
Overall Activity Level:
Please select from drop down options.
Very Little
Little
Moderate
Active
Very Active
Please describe your activities and exercise:
If you do not currently exercise, have you exercised in the past? If yes, how often and what kind of exercise?
Average or Typical Daily Meals (List items & amount):
Please describe your typical breakfast, lunch, dinner and snack(s).
Do you drink alcohol?
Yes
No
If yes, how much/ often/ what type?
Have you ever used any diet shakes/pills? If so, what was the result?
Have you ever been prescribed medication to control high blood pressure?
Yes
No
Do you smoke?
Yes
No
Have you ever been diagnosed with heart problems?
Yes
No
Do you suffer from chest pain?
Yes
No
Do you ever feel faint or have spells of dizziness?
Yes
No
Have you ever been prescribed medication for heart problems?
Yes
No
Have you ever been diagnosed with joint or soft tissue problems?
Yes
No
Please explain any checked boxes to the questions above.
Do you have any current medical problems or incompletely healed injuries?
Yes
No
If you answered yes to the above question, please explain below.
Check the box next to any recurring problems you have:
Upper Back
Lower Back
Neck
Shoulders
Elbows
Wrists
Hips
Knees or Ankles
Please explain any checked boxes to the questions above.
What if any surgeries have you had performed and when?
Date of last physical exam:
MM
DD
YYYY
Date of last fitness assessment:
MM
DD
YYYY
I have read all of the above information and completed it to the best of my knowledge.
Please enter your full name and today's date.
Thank you!
