Building people
from the ground up
(949) 588-8193

Building people from the ground up (949) 588-8193

Client Information Form
Items in yellow are required
How did you hear about us? (*)
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Personal Information
Name: (*)
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Address: (*)
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City: (*)
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State: (*)
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Zip Code: (*)
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Email Address: (*)
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Home Phone #:
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Work Phone:
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Cell Phone:
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D.O.B. (*)
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Height:
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Weight (current) (*)
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Weight (1 yr. Ago) (*)
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Health Information
Have you exercised within
the past 6 months? (*)
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Type of exercise and duration:
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Are you dieting?
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Type of diet:
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Eating habits:
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Do you smoke?
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If yes, how many
cigarettes per week?
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Do you drink?
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If yes, how many alcoholic beverages per week?
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Health History
Indicate any diseases or
illnesses you had
or currently have:























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If you answered yes to any of the above questions, please explain in further detail:
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Are you currently taking any medication? (*)
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If yes, specify type and dosage:
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When was your last Physical Examination?
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Physician's Name:
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Phone:
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Have you had a stress test? (*)
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Cholesterol Profile:
HDLs
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LDLs
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Totals:
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Emergency Care

By submitting this form I hereby give consent to the trainers to provide emergency care to me in the form of CPR or first aid in cases where it is deemed necessary. Any other treatment or care that is needed will be provided at my expense.
Emergency Care Disclaimer: (*)
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Date
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