Form

Personal Information Personal Information

Name

Date of Birth

Phone Number

Email Address

Emergency Contact Name & Relationship

Emergency Contact Phone Number

Health History Health History

Do you have any of the following conditions? Select all that apply: Do you have any of the following conditions? Select all that apply: Heart Disease High Blood Pressure Diabetes Asthma or Respiratory Issues Arthritis Osteoporosis Chronic Pain Recent Surgery (within the past 12 months) None of the above

Other:

Are you currently taking any medications that may affect your physical activity? Are you currently taking any medications that may affect your physical activity? Yes No

If yes, please specify:

Have you experienced any injuries, surgeries, or conditions that may impact your exercise routine? Have you experienced any injuries, surgeries, or conditions that may impact your exercise routine? Yes No

If yes, please specify:

Do you have any allergies or medical conditions I should be aware of? Do you have any allergies or medical conditions I should be aware of? Yes No

If yes, please specify:

Lifestyle & Fitness Goals Lifestyle & Fitness Goals

How would you rate your current activity level? How would you rate your current activity level? Sedentary (little or no exercise) Lightly Active (1–3 days/week) Moderately Active (3–5 days/week) Very Active (6–7 days/week)

What are your primary fitness goals? Select all that apply: What are your primary fitness goals? Select all that apply: Weight Loss Muscle Gain Improved Flexibility Increased Endurance Pain Reduction Improved Mental Health

Other:

Do you currently follow any specific diet or nutrition plan? Do you currently follow any specific diet or nutrition plan? Yes No

If yes, please specify:

Have you worked with a personal trainer before? Have you worked with a personal trainer before? Yes No

What is your preferred workout location? What is your preferred workout location? Home Park Gym

Other:

Consent & Agreement By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that Potentiate Fitness is not a substitute for medical care and that I should consult my healthcare provider before beginning any exercise program if I have concerns. SaveClear

Date