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Red City Fitness

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617-380-4949

Personal Information

First Name

Last Name

Email

Phone

Occupation

Employer

Primary Physician

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone:

How did you hear about us?

How many days per week are you active?

None

1-2

3-4

5-6

Everyday

Are you taking any medications?

Yes

No

If yes, please list name and use

Are you currently pregnant?

Yes

No

If yes, how far along:

Any high risk factor?

Do you suffer from chronic pain?

Yes

No

Do you suffer from any medical conditions?

Yes

No

If yes, what condition

Have you had any ortopedic injuries?

Yes

No

If yes, please list

Do you have any allergies or sensitivities?

Yes

No

Not Sure

If yes, please explain

What are your fitness goals?

Height

Weight

Chest

Waist

Hips

Thighs

Calf

Body Fat/BMI

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Red City Fitness
1 Braintree St, Allston, MA, 02134
Boston, Massachusetts
617-202-1056
redcityfitness@gmail.com
Fully Insured

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