Client Information Questionnaire

Please complete the form below prior to your first scheduled session or scheduled parent orientation session.

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals, and is safe and effective.

Client Information

First Name

Last Name

Email Address

Date of Birth

Age

Cell Phone

Home Phone

Work Phone

Address

City

State

Zip

Occupation

Emergency Contact Information

Emergency Contact

Emergency Contact Phone

Relationship

Additional Emergency Phone

Physician Information

Physician's Name

Physician's Phone

Physician's Address

City

State

Zip

Your Performance Coach will send information to and seek clearance and instruction regarding your physical exercise program from your physician unless you request otherwise.

Message/Comments

Questions? Need help scheduling?

Contact GSC

Client Information Questionnaire