Fitness Assessment Form
Client Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Emergency Contact Person
*
First Name
Last Name
Phone Number of Emergency Person
*
-
Area Code
Phone Number
Physician Name
First Name
Last Name
Physician Phone Number
-
Area Code
Phone Number
Health-Related Questions
Are you currently taking any exercise program?
*
Yes
No
If yes, What programs are taking now or most recently?
Height (in)
*
Weight (lbs)
*
BMI
Body Fat %
Do you have the following conditions?
*
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
None of the above
Other
Are you a smoker?
*
Yes
No
Are you pregnant (Female only)?
*
Yes
No
Do you drink alcohol?
*
Yes
No
How many times do you exercise in a week?
*
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
*
Yes
No
Other
What do you usually eat for breakfast?
What do you usually eat for lunch?
What do you usually eat for dinner?
Are you currently taking medications? If yes, what are the medications and for what purpose?
*
Have you had any injuries in your body? If yes, please indicate the location
*
Have you been previously hospitalized? If yes, please indicate when and why.
*
Did you undergo any surgeries in the past? If yes, please indicate the type of surgery
*
Training Preferences
What time of day are you available for training:(Mornings, Midday, or Evenings; give specific time frames if possible)
How many days a week would you like to train?
2 days a week
3 days a week
Goals
What are your goals in this program?
*
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
Other
How did you hear about us?
What’s your T-Shirt Size?
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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