Name

Address

Phone

Email

Date of Birth

Age

Weight

Occupation

Medical History:Choose from the list below and comment if any apply.

Heart Condition Surgery Neck Injury Back Injury Head Injury Joint Injury Bone Fractures Gout Hepatitis Smoking Allergies Diabetes Depression Arthritis Hernia High Cholestrol High Blood Pressure Cancer Stroke Eating Disorder Asthma Ulcer Lung Disease Fibromyalsia Thyroid Problems Substance Abuse Hormonal

Please comment on any of the conditions that you may have from the list above.

Do you belong to a gym/fitness center?

Yes No

If not do you have access to gym/fitness equipment?

Yes No

If you answered yes to the previous question: Please briefly describe the brand of equipment and the assortment or classification of the machines.

Have you ever worked with a trainer before?

Yes No

Will you have access to free weights?

Yes No

Do you currently have a workout/fitness program? If yes please describe it, including how many days a week you engage in the program. If no, but do workout regularly please describe it.

Have you in the past belonged to a gym or worked out on a regular basis? If yes when and for how long?

Do you or have you ever played sports competitively? If yes please describe.

What is your knowledge level about diet and nutrition?

High Medium Low

What is your knowledge level about resistance/weight training

High Medium Low

What is your knowledge level of cardiovascular training?

High Medium Low

How many meals do you currently eat a day?

One Two Three Four Five Six

How many snacks do you currently eat a day?

None One Two Three

What is your goal or plan concerning a fitness program?

How many days per week will you be committed to engaging in a personalized fitness program?

Seven Six Five Four Three Two

Do you take any vitamins and/or supplements? If so, please list them.

Have you consulted a physician, regarding your decision to begin a fitness/nutrition program? If yes, please provide a physicians note. If no, please authorize that you are physically and mentally able to participate in a physical activity.

I Authorize that I am physically and mentally able to participate in physical activity. Client Signature: Date:

Any comments, questions or pertinent information please provide below.