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Home
Rates
About Kim
Specialties
Testimonials
Contact
Kim Brownlee, CPT-ACSM
www.kimmovin.com
Name
*
First Name
Last Name
Phone
(###)
###
####
Email Address
*
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
(###)
###
####
Your Preferred Method to Comunnicate
*
Call
Text
Email
Current Occupation?
Do you sit for long periods of time?
yes
no
Do you have extended periods of movement
Yes
No
Do you where shoes with heels?
Yes
No
Are you involved or partake in recreational activities (skiing, golfing, rollerblading)?
Do you have or ever had pain or injuries? Please list and describe your injuries.
Have you had any surgeries?
Yes
No
If yes, when?
Please explain
Has a medical doctor ever diagnosed you with a chronic disease such as Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD), Hypertension (high blood pressure), High Cholesterol, Diabetes, etc.?
Yes
No
If yes, please explain
Are you currently taking any medications? If yes, please explain.
Do you know your resting heart rate?
Yes
No
If yes, what is your RHR?
THR (Target Heart Rate)?
I certify that the above information is accurate. I have consulted with my physician before starting an exercise program.
*
Yes, I have consulted with my physician before starting an exercise program.
No, I have not consulted my physician.
I understand that I may need a medical release before I begin an exercise routine. I release the liability of trainer, Kim Brownlee and Fremont Health Club facility.
*
I have read and agree to the statements above.
E-Signature
Today's date
MM
DD
YYYY
Thank you!
