Client Information Form Step 1 of 4 25% Personal InformationFirst Name*Last Name*Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Birthday* MM DD YYYY Height*Weight* Health and Fitness GoalsHealth and fitness goals (check all that apply)* Injury rehab Injury prevention Cardiac health Weight loss Core strength building Muscle building Endurance Marathon/triathlon training Stress relief More specific health/fitness goals (optional) How often can you commit to your workout program? (This is how often you will workout, not how often you will have training sessions with us)*1-2 days per week3-4 days per week4-5 days per week6-7 days per weekWhere do you prefer to workout (check all that apply)?* Home Outdoors Yoga Hale (our yoga and fitness center) Other fitness center Other fitness centerWhat fitness activities are you interested in (check all that apply)?* Running Cycling Swimming Weights Exercise machines Yoga Pilates Water activities Do you currently have any exercise equipment you like to use at home (e.g. dumbbells, treadmill, ball)?Will you consider purchasing small exercise equipment (e.g. dumbbells, ball)?*YesNoWhat is your recent exercise history like? Cardiac Risk FactorsDo you have any heart conditions?*YesNoDescribe heart conditions Do you have high blood pressure?*YesNoFamily history of heart conditions?*YesNoStress level*LowMediumHighDo you smoke?*YesNoActivity level per week?*LowMediumHighAny other cardiac concerns? Orthopedic Conditions or InjuriesCervical spine issues?*YesNoDescribe cervical spine issues Thoracic spine issues?*YesNoDescribe thoracic spine issues Lumbar or sacroiliac issues?*YesNoDescribe lumbar or sacroiliac issues Shoulder issues?*YesNoDescribe shoulder issues Elbow, wrist, hand issues?*YesNoDescribe elbow, wrist, hand issues Hip issues?*YesNoDescribe hip issues Knee issues?*YesNoDescribe knee issues Ankle or foot issues?*YesNoDescribe ankle or foot issues Sciatica issues?*YesNoDescribe sciatica issues Any other orthopedic conditions or injuries not mentioned above? That's all, just hit Submit below!EmailThis field is for validation purposes and should be left unchanged.