LISA KINDER METHOD
Become the BEST version of Yourself
Client Information
Fitness Assessment Form
IMPROVE Physically, Mentally & Emotionally.
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 participating in an exercise program?
*
Yes
No
If Yes, How many days a week?
*
0-1
1-3
3-5
7 days a week
*
BMI
*
Please Take A Bio Photo:
*
Body Fat %
*
*estimate if you are unsure*
Do you have the following conditions?
*
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
Other
Are you a smoker?
*
Yes
No
Are you pregnant (Female only)?
*
Yes
No
Do you drink alcohol?
*
Yes, 0-3 a week
Yes, 3-7 a week
Yes, 7+ a week
No, I don't drink
How many times do you exercise in a day?
*
What type of workouts do you do, enjoy or have interest in?
*
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
*
Yes
No
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
*
What are your goals in this program?
*
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
How much time in a week can you provide to a program?
*
What is the "biggest challenge" that is in your way of achieving your goal(s)?
*
During any program via In person or virtual, if my medications, condition, or medical limitations should change I will notify the Trainer. I understand that it is recommended that I have a yearly physical or more frequent physical examination and consultation with my physician as to physical activity and diet so I am aware of what is appropriate for me. I acknowledge that I have either had a physical exam and have been given my physician's permission to participate or I have decided to participate without approval of my physician. I understand that a trainer will review my Lifestyle Questionnaire and any other health history form but that a trainer is not a physician and cannot replace the advice and expertise of a physician. I understand that I have the complete right to stop or decrease exercise at any time during a session and that it is my obligation to inform the trainer of any symptoms such as fatigue, shortness of breath or chest discomfort. I realise that participation in the programme including but not limited to exercising, use of exercise equipment and strenuous exertion (strength training) all of which increase heart rate and body temperature. I understand that exercise involves certain risks and that injuries may occur (including slips, falls and unintended loss of balance). I understand that part of the risk involved in undertaking any activity or programme is relative to my own state of fitness or health (physical, mental or emotional) and to the awareness, care and skill which I conduct myself in that activity or programme. Knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risks of injury, and even risk of possible death, which could occur by reason of my participation. Please type your name below.
*
Client Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: