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Welcome to GYM NYC DWTN BROOKLYN 


We are thrilled to have you join our community of high-performing individuals who prioritize health, wellness, and a luxury fitness experience. To ensure we design a customized and effective fitness program tailored specifically to you, we ask that you complete the following Health History form. Please answer all questions accurately and honestly. Your information will remain strictly confidential.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
HEALTH HISTORY

HEIGHT

WEIGHT
Has a physician ever informed you of any heart conditions?*
No
Yes
Do you have or have you ever had high blood pressure?*
No
Yes
Have you experienced chest pain, dizziness, or fainting during physical activity?*
No
Yes
Have you undergone any major surgery in the past six months?*
No
Yes

If yes, please specify:
Do you have any diagnosed medical conditions (such as diabetes, asthma, arthritis, high cholesterol)?*
No
Yes

If yes, please specify:
Are you currently taking any prescribed medications?*
No
Yes

If yes, please list medication, dosage, and the condition being treated:
Do you currently experience pain or have injuries?*
No
Yes

If yes, please provide details:
Are you currently receiving any treatment from a health professional (physiotherapist, chiropractor, massage therapist, etc.)?*
No
Yes

If yes, please specify:
How would you describe your current exercise level?
NONE
2-3 TIMES PER WEEK
4-5 TIMES PER WEEK
What is your primary fitness goal?
WEIGHT LOSS
MUSCLE GAIN
STRESS REDUCTION
IMPROVED POSTURE
CARDIOVASCULAR CONDITIONING
LONGEVITY

On average, how many hours of sleep do you get per night?

Is there anything else we should know that may limit your exercise ability?
LIABILITY WAVIER

In consideration of my participation at GYM NYC DWTN BROOKLYN, I acknowledge and agree to the following:

  1. Assumption of Risk: I understand that participating in any fitness activity involves inherent risks of injury, including but not limited to muscle soreness, strains, or more severe physical injury. I voluntarily accept these risks.
  2. Release of Liability: I agree to release and discharge GYM NYC DTWN BROOKLYN and its staff from any and all claims of injury, damages, or loss that may arise during my participation in fitness activities.
  3. Medical Clearance: I confirm that I have consulted with a physician (or voluntarily waive this right) regarding my fitness participation. I understand that I am responsible for my own physical health and well-being.
  4. Facility Usage: I agree to follow all rules, guidelines, and instructions provided by the staff to ensure a safe and optimal fitness experience.


Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's EMERGENCY CONTACT

NAME

RELATIONSHIP

TELEPHONE NUMBER
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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