Client Intake Form

Name*

First Last

Phone*

Date of Birth*

Email*

Emergency Contact Name & Number

Exercise 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.*

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*

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