New Member Health Assessment & Intake Form
Please complete this form before your first visit. It helps us understand your health history and goals so we can build a program that's safe and effective for you.
Who is this form for?
Your selection determines which waiver(s) will appear at the bottom of this form.
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Adult Member
18 years or older
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Minor Member
Ages 8β17 (parent must complete)
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Adult + Minor
Parent joining with a child
1 Personal Information
2 Emergency Contact & Physician
3 Medical History β Diagnosed Conditions
Y = Yes Β· N = No Β· FH = Family History
Heart Disease / Cardiac Condition
Diabetes (Type 1 or 2)
Stroke / TIA
Hypertension (High Blood Pressure)
High Cholesterol
Metabolic Disorder
Blood Sugar Irregularity / Pre-diabetes
Thyroid Disorder
Neurological Condition
Parkinson's Disease
Osteoporosis / Osteopenia
Arthritis (Osteo or Rheumatoid)
Cancer (current or history)
Seizures or Fainting
Asthma / Respiratory Condition
Depression / Anxiety / Mental Health
Musculoskeletal / Back / Joint Issues
Obesity / Weight-related Condition
4 Current Medications & Supplements
| Medication / Supplement | Dosage | Frequency | Reason |
|---|---|---|---|
5 Physical Activity History
6 Nutrition & Lifestyle
7 Health & Fitness Goals
8 Symptom Assessment
Scoring: 0 = Never | 1 = Mild / Occasional | 2 = Moderate / Frequent | 3 = Severe at Times | 4 = Severe / Often
Rate symptoms over the past 3 months.
Rate symptoms over the past 3 months.
Emotional
Mood Swings
Anxiety
Anger / Aggression
Depression
Brain Fog / Confusion
Category total: 0
Energy & Sleep
Fatigue / Low Energy
Apathy / Lethargy
Hyperactivity / Restlessness
Trouble Sleeping / Insomnia
Difficulty Concentrating
Category total: 0
Digestive & Appetite
Nausea / Vomiting
Diarrhea / Constipation
Bloating / Gas / Heartburn
Binge Eating / Loss of Appetite
Cravings (sugar, salt, carbs)
Category total: 0
Musculoskeletal
Joint Pain / Stiffness
Back Pain
Loss of Strength
Loss of Balance / Coordination
Loss of Muscle Mass
Category total: 0
Cardiovascular & Respiratory
Chest Pain / Tightness
Shortness of Breath
Irregular Heartbeat
Faintness / Dizziness
Persistent Cough
Category total: 0
Metabolic & Immune
Unexplained Weight Gain
Unexplained Weight Loss
Extreme Thirst / Frequent Urination
Hot Flashes / Night Sweats
Frequent Illness / Colds
Category total: 0
Neurological
Headaches / Migraines
Memory Issues / Forgetfulness
Tremors / Shaking
Numbness / Tingling
Speech / Swallowing Changes
Category total: 0
Skin, Eyes & Nasal
Skin Eruptions / Rashes
Itchy / Watery Eyes
Vision Changes
Nasal Congestion / Sinus Issues
Ear Ringing / Hearing Changes
Category total: 0
Total Symptoms Score
Lower is better Β· Max score: 160
0
10 Final Confirmation & Submission
How to submit this form:
1) Click Print / Save PDF below and save the completed form to your device.
2) Click Email Completed Form β your email program will open with the address and subject already filled in. Attach the PDF you just saved, then hit send.
You're also welcome to print this form and bring it with you to your first visit instead.
1) Click Print / Save PDF below and save the completed form to your device.
2) Click Email Completed Form β your email program will open with the address and subject already filled in. Attach the PDF you just saved, then hit send.
You're also welcome to print this form and bring it with you to your first visit instead.
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Your email program should now be open. Don't forget to attach the PDF you saved before sending. We look forward to seeing you at RSF!