Information and privacy: questions regarding the collection of information on this form can be directed to the form administrator.

Date of birth * (required)
You are: * (required)
What would you like to accomplish with our services? Be as specific as possible (e.g. lose weight, increase strength, train for a specific sport).
Current and previous activity * (required)
Do you currently participate in some sort of physical activity on a daily/weekly basis (e.g. lifting, cardiovascular activity, recreational or other unstructured physical activities that are part of your daily life/job)?
Include type of activities, frequency (times per week), intensity (number of sets and repetition of weights, or low/moderate/high for cardio), duration of activity, or any other pertinent details.
Include how long ago and brief details regarding the activity.
What service(s) are you interested in? * (required)
Please list and describe any injuries or chronic conditions that may impact exercise tolerance (e.g. high blood pressure, arthritis, shoulder injury).
Please list current medications and dosages.