New Client Intake Form

Thank you for considering Berg Balanced Health as part of your wellness journey. Creating an inclusive and safe experience is the top priority, which is why the below form asks additional questions regarding your health history, lifestyle and expectations. Please provide as much information as you feel comfortable doing, and feel free to reach out if you have any questions.

Name

First Name

Last Name

Prounouns

Phone

Date of Birth

YYYY

Emergency Contact (Name, phone number and relationship)

Is this your first time working with a fitness professional?

Yes

If you have worked with a fitness professional before, please provide information on that experience (what you liked, what you didn't).

How would you describe your current level of overall health (movement, nutrition, sleep, etc.)

What are your key areas of focus as it relates to your overall health?

Are you able to comfortably get down on the ground and up again?

This information is only used to aid in the development of programming that best supports you and your body.

Are you comfortable walking up/down a flight of stairs?

This information is only used to aid in the development of programming that best supports you and your body.

Are there any specific movements that make you feel uncomfortable?

This information is only used to aid in the development of programming that best supports you and your body.

What type of movement, if any, makes you feel your best?

What type of movement, if any, makes you feel your worst?

Do you have any current or past injuries? If so, please provide details.

What does fitness success look like to you?

How often do you see a General Physician and/or a medical professional?

What fears or uneasiness, if any, do you have about getting started?

Is there anything else you would like to share?