Rock Solid 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
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
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 day?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
What do you usually eat in breakfast?
What do you usually eat in lunch?
What do you usually eat in 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 in this program?
Client Signature
Date Signed
-
Month
-
Day
Year
Date
My Products
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12 week Nutrition & Fitness program (on your own)
$
299.99
12 week Nutrition & Fitness program (on your own) Our 12 week fitness and nutrition program will help you increase your strength, speed, endurance, balance, lean mass and improve overall wellness (mentally, physically, emotionally and nutritionally). This program is created for at home workouts or at the gym. Great for all levels from beginners to intermediate. Let us take all the guesswork out of what, when, where and how to get started. Let us help you!
Quantity
At home option
1
2
3
4
5
6
7
8
9
10
Gym option
1
2
3
4
5
6
7
8
9
10
8 Sessions ( Bundle deal)
$
320.00
Personal Training 8 Personal Training session. These sessions are available remote or in person at Rock Solid Fitness in Quitman. Sessions must be used within 6 weeks of booking.
Quantity
1
2
3
4
5
6
7
8
9
10
Trainers
Brook Rogers (all clients)
Joel Landers (advanced clients & athletes)
Lottie Boll (beginner clients)
Ruthie Bybee (seniors & beginner)
Monthly Nutritional Coaching
$
199.99
1 Month Nutritional Coaching Typical diets lead to short term results followed by burnout, and sometimes leave you right back where you started. I teach how to eat the foods you love, enjoy your social life, AND stay on track with your goals. You will receive custom calorie & macronutrient goals. Flexible meal plans & recipes.
Subtotal
$
0.00
Tax
$
0.00
Total
$
0.00
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