Ambition Health & Performance | Osteopathy | Personal Trainer | Massage | Online Personal Training

0207 630 5930 | info@ambitionfitness.com

3 x 1 hour Personal Training Sessions for £90
For all your Corrective, Rehab and Fitness requirements
Email info@ambitionfitness.com_

New Clients

Please fill out the form below ahead of your first visit.

Client / Patient Details

Please complete all of the required fields below

Name *

Address *

City *

County *

Postal Code *

Home Telephone *

Business Telephone *

Mobile *

Email *

Emergency Contact Phone *

Relationship *

Date of Birth *

Medical

Check the appropriate response. Read all questions thoroughly.

1. Has your doctor ever told you that you have heart problems? *

2. Has your doctor ever told you that you have a high blood pressure? *

3. Have you ever had a stroke or heart attack? *

4. Have you ever had pain in your chest? *

5. Do you feel faint or have dizzy spells? *

6. Have you had surgery in the last 6 months? *

7. Do you smoke? *

B. Check the appropriate conditions.

Diabetes

Epilepsy

Blood Pressure

Asthma

Arthritis

High Cholesterol

Heart

Pregnancy

Are you currently taking any medications? *

If you checked "yes", please list medications, dosage, and for what condition

Injury History

Have you injured or have pain in the following areas? Check the appropriate lines.

Neck

Upper Back

Shoulders

Elbows

Lower Back

Hips

Wrists

Knees

Other

Additional Details

Are you currently undergoing treatment from any of the following? Physiotherapist, Chiropractor or a Massage Therapist. If yes, please state why:

Lifestyle

What is your current exercise level? *

What type?

How would you rate your level of stress on a daily basis? *

Estimate how many hours of sleep you get each night *

Any Additional Information

Informed Consent / Participant Release * I hereby consent to voluntarily engage in a Corrective Exercise, Injury Rehabilitation or Personal Training Program with Ambition Heath & Performance. click here

I Agree

Please ensure you have filled out all required fields

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Queen Mother Sports Centre,
223 Vauxhall Bridge Rd,
London,
SW1V 1EL
&
Core Gym,
8 Members Club,
8 Dysart St
London,
EC2A 2BX

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T: 020 7630 5930
E: info@ambitionfitness.com

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