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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*
Date of Birth
First Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's EMERGENCY CONTACT
NAME
RELATIONSHIP
TELEPHONE NUMBER
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
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*
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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