Health Screening Form

Collect body measurements, medical background, injuries and fitness goals in a single submission. Gyms, wellness centres and personal trainers use it before assigning any programme. It also asks which channel brought the client in and which services appeal to them.

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Full name

Nombre

Apellido

Phone number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency contact number

Date of birth

Height in centimetres

Weight in kilograms

Sex

Female Male Prefer not to say

Are you active on a daily basis?

Yes No

Are you pregnant?

Yes No Not applicable

What do you do for a living?

Did one of our clients recommend us to you?

Yes No

If yes, give their name so we can thank them

Nombre

Apellido

If not, how did you hear about us?

Social media Search engine A friend or relative Advertising An event Passing by the premises

Which of our services interests you most?

Personal training Nutrition coaching Group classes Physiotherapy Health screening

Have you ever had any of these conditions?

Has a close relative had any of these conditions?

Have you had surgery in the past two years?

Yes No

If yes, give the details

Do you suffer from back pain?

Yes No

If yes, give the details

Do you have any injuries?

Yes No

If yes, give the details

Do you take any of these?

Prescription medication Sports supplements Vitamins None of these

If yes, list them

When were you in the best shape of your life?

What were you doing then and what has changed since?

How would you describe your eating habits?

Excellent Good Average Poor

Have you experienced any of these symptoms?

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