Joe Butler Pre-Assessment

Pre-Assessment Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

How did you hear about us?(Required)

Which location would you want to workout at?(Required)

Emergency Contact Name

First Last

Emergency Contact Phone Number

Tell Us About Yourself

We collect detailed information up front so we can create a plan that’s tailored specifically to you—your goals, your health history, and your lifestyle. The more we know, the better we can help you train smarter, safer, and more effectively from day one.

Date of Birth

Height

Weight

Describe any physical activity you do somewhat regularly:

History of heart problems, chest pain, high bp, or stroke?

Yes

No

Any chronic illness or condition?

Yes

No

Any recent surgeries? (12 months)

Yes

No

Pregnancy? (now or within the last 3 months)

Yes

No

Hernia of any condition aggravated by lifting weights?

Yes

No

Muscle, joint or back disorder or previous injury still affecting you?

Yes

No

List any other medical conditions or information not listed above

Were you a high-school athlete?

Yes

No

If so, please specify

Do you have any negative feeling towards, or have had any bad experience with a physical activity program?

Yes

No

If so, please specify

Do you start exercise programs but then find yourself unable to stick with them?

Yes

No

If so, please specify

How many days a week are you willing to devote to an exercise program?

Please enter a number from 1 to 7.

What days and times fit your schedule best for training?

What types of exercise interest you? Check all that apply

Walking

Biking

Swimming

Eliptical

Strength Training

Mobility/Flexibility

List your top 3 health and fitness goals...

By submitting this form, you consent to receive SMS messages from Prescription Fitness.(Required)

I consent to receive SMS messages from Prescription Fitness

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Phone

This field is for validation purposes and should be left unchanged.

Pre-Assessment Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

How did you hear about us?(Required)

Which location would you want to workout at?(Required)

Emergency Contact Name

First Last

Emergency Contact Phone Number

Tell Us About Yourself

We collect detailed information up front so we can create a plan that’s tailored specifically to you—your goals, your health history, and your lifestyle. The more we know, the better we can help you train smarter, safer, and more effectively from day one.

Date of Birth

Height

Weight

Describe any physical activity you do somewhat regularly:

History of heart problems, chest pain, high bp, or stroke?

Yes

No

Any chronic illness or condition?

Yes

No

Any recent surgeries? (12 months)

Yes

No

Pregnancy? (now or within the last 3 months)

Yes

No

Hernia of any condition aggravated by lifting weights?

Yes

No

Muscle, joint or back disorder or previous injury still affecting you?

Yes

No

List any other medical conditions or information not listed above

Were you a high-school athlete?

Yes

No

If so, please specify

Do you have any negative feeling towards, or have had any bad experience with a physical activity program?

Yes

No

If so, please specify

Do you start exercise programs but then find yourself unable to stick with them?

Yes

No

If so, please specify

How many days a week are you willing to devote to an exercise program?

Please enter a number from 1 to 7.

What days and times fit your schedule best for training?

What types of exercise interest you? Check all that apply

Walking

Biking

Swimming

Eliptical

Strength Training

Mobility/Flexibility

List your top 3 health and fitness goals...

By submitting this form, you consent to receive SMS messages from Prescription Fitness.(Required)

I consent to receive SMS messages from Prescription Fitness

Reply "STOP" to unsubscribe. Standard message and data rates may apply. Your information will be handled in accordance with our Privacy Policy.

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

How did you hear about us?(Required)

Which location would you want to workout at?(Required)

Emergency Contact Name

First Last

Emergency Contact Phone Number

Tell Us About Yourself

We collect detailed information up front so we can create a plan that’s tailored specifically to you—your goals, your health history, and your lifestyle. The more we know, the better we can help you train smarter, safer, and more effectively from day one.

Date of Birth

Height

Weight

Describe any physical activity you do somewhat regularly:

History of heart problems, chest pain, high bp, or stroke?

Yes

No

Any chronic illness or condition?

Yes

No

Any recent surgeries? (12 months)

Yes

No

Pregnancy? (now or within the last 3 months)

Yes

No

Hernia of any condition aggravated by lifting weights?

Yes

No

Muscle, joint or back disorder or previous injury still affecting you?

Yes

No

List any other medical conditions or information not listed above

Were you a high-school athlete?

Yes

No

If so, please specify

Do you have any negative feeling towards, or have had any bad experience with a physical activity program?

Yes

No

If so, please specify

Do you start exercise programs but then find yourself unable to stick with them?

Yes

No

If so, please specify

How many days a week are you willing to devote to an exercise program?

Please enter a number from 1 to 7.

What days and times fit your schedule best for training?

What types of exercise interest you? Check all that apply

Walking

Biking

Swimming

Eliptical

Strength Training

Mobility/Flexibility

List your top 3 health and fitness goals...

By submitting this form, you consent to receive SMS messages from Prescription Fitness.(Required)

I consent to receive SMS messages from Prescription Fitness

Reply "STOP" to unsubscribe. Standard message and data rates may apply. Your information will be handled in accordance with our Privacy Policy.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.