Client Information Sheet - Ymca Of Kingston printable pdf download

Client Information Sheet

Trainer

_______________

__________________ __________________

____________

_________

Last Name

First Name

Membership #

Age

__________________ _______________________ _________________________

Home Phone #

Alternate Phone #

E-Mail Address

Session Date: _________________ Time: ________________________

Do you have any health conditions that could interfere with your ability to exercise?

(If yes please explain)

________________________________________________________________

Please indicate if you have any pain or discomfort in the following areas:

o Neck

o Shoulder R/L

o Hip R/L

o Back Upper/Lower

o Elbow R/L

o Wrist R/L

o Ankle R/L

o Knee R/L

o Other ( please specify)____________________________

GOALS: Please describe what you would like to accomplish during your session with

your trainer.

________________________________________________________________

How would you describe your exercise history?

o I am not currently active

o I am currently active but have begun doing so in the last 6 months.

o I participate in regular activity and have done so for more that 6 months.

Comments:

________________________________________________________________

If you need to reschedule your appointment please give us a call @ 613-546-2647 x247.

Please leave this completed form with our Member Services Staff.

Privacy statement: the YMCA of Kingston is committed to protecting personal

information by following responsible information handling practices in keeping with

privacy laws. For more information please visit our website @

Client Information Sheet - Ymca Of Kingston