Client Intake Form Before attending a PropelFit class, please complete the form below. This information is necessary for your program. We understand this information is personal and you have our assurance it will be kept confidential. Name* First Last Phone*Date of Birth* Email* Emergency Contact Name & NumberExercise Frequency?*Exercise Type(s)?*What medication/s are you currently taking?Do you have any previous injuries, surgeries or illness?*Please tick which of the following relates to you.* Asthma Diabetes Headaches Pregnancy Depression Epilepsy Heart Disease Pace Maker Arteriosclerosis Low Blood Pressure High Blood Pressure Dizziness Inflammation Arthritis Cancer Stomach Ulcer Severe Pain None of the above Are there any other conditions we should know about which might affect your participation in an exercise program ? If so, please specify:I hereby agree that all the information on this form is accurate to the best of my knowledge. If it changes during the course of my membership, I will consult one of the Propel team. I understand that my participation in any program is voluntary and I can stop exercising at any time, particularly if I am feeling pain or discomfort.* Yes Please add your name here as signature of acceptance of above*Date* CAPTCHAUntitledFirst ChoiceSecond ChoiceThird Choice