SouLift Fitness Member Health Assessment

Member Information

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* 1. Contact Information

Name

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. Best method of contact:

Phone call

Text

E-Mail

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* 3. Best Time of Day to Contact

Morning

Afternoon

Evening

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* 4. Best Day/Time for Appointments

	Mon	Tues	Weds	Thurs	Fri	Sat	Sun
Morning	Morning Mon	Morning Tues	Morning Weds	Morning Thurs	Morning Fri	Morning Sat	Morning Sun
Afternoon	Afternoon Mon	Afternoon Tues	Afternoon Weds	Afternoon Thurs	Afternoon Fri	Afternoon Sat	Afternoon Sun
Evening	Evening Mon	Evening Tues	Evening Weds	Evening Thurs	Evening Fri	Evening Sat	Evening Sun

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* 5. Date of Birth (MM/DD/YY)

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* 6. Height (Feet-Inches)

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* 7. Current Body Fat Percentage

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* 8. Current Weight (pounds)

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* 9. Goal Body Fat Percentage

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* 10. Goal Body Weight

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* 11. Emergency Contact Information

Contact Name

Relationship

Phone Number