Comprehensive Client Information Form

This is your comprehensive client information form. With this form, we will ask you to provide some relevant personal information. The answers to these questions are essential in order to allow us to design an optimized individual fitness program for you. Please answer all questions in the most accurate manner possible while being as concise as possible. Please recognize the fact that it is your responsibility to work directly with your physician before, during, and after seeking fitness consultation. As such, any information provided is not to be followed without the prior approval of your physician. If you choose to use this information without the prior consent of your physician, you are agreeing to accept full responsibility for your decision.
Basic Information
Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you prefer a consultation over the phone or on Zoom?
1) What is your sex?
2) What is your age?
3) What is your date of birth (month/day/year)?

MonthDayYear
Date
4) What is your height?
5) What is your current weight?

6) What are your specific goals (rank these goals according to importance with 1 being the most important and 7 being the least)?*

	1	2	3	4	5	6	7
Improved Health
Improved endurance
Increased Muscle Mass
Fat Loss
Increased Strength
Increased Power
Weight Gain

7) Is there a specific timeline for achieving a specific goal?
8) Select which of the two are of greater importance for you

Immediate progress that's less easily maintainedMaintainable progress that may not be as rapid
Please explain why
Exercise Information
9) Are you currently exercising regularly (at least 3x per week)?

YesNo
If you answered YES, continue on to question 10. If you answered NO, continue on to question 13.
10) How long have you been consistently exercising without a break?

11) On the following charts , fill in which type of exercise you normally perform each day: "Examples" resistance training (RT); interval cardio bouts (ICB); low-in- tensity cardio bouts (LICB); sport-specific work (SSW) and then the approximate duration for each day in minutes.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Type of exercise

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Duration

12) Describe your current exercise regimen in detail.
13) If you are not currently exercising regularly, have you ever been on a consistent exercise plan (at least 3x per week)? select one

YesNo
If you answered YES, how long ago was it, and how long did it last?
Lifestyle Information
14) What do you do for a living?
15)What is the activity level at your job?
16) Describe your work schedule. I.E- Does your Work schedule stay the same or does it change daily/weekly? Do you work days, afternoons or nights?
17) How often do you Travel?

RarelyFew times per yearFew times per monthWeekly
18) Please list the physical activities that you participate in outside of the gym and outside of work.
19) If you have any diagnosed health problems, list the condition(s).
20) If you are on any medications, please list them.
21) If you listed any conditions above, What additional therapies or interventions are being undertaken for the given health problem(s)?
22) If you have any injuries, please list them.
23) What additional therapies or interventions are being undertaken for the given injury(s)?

24) Please fill out the following timetable with your most normal daily schedule listing the time you wake up, work and have breaks, work out, and go to sleep.

	AM	PM
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00

25) Exactly how much money do you spend on groceries per month (provide amounts from your last two grocery bills)?
26) How often do you grocery shop (number per week)?
27) How many meals do you eat in restaurants or fast food places per week?
28) Exactly how much money do you spend on supplements per month?
29) Are there any other foods to which you're particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness, or congestion)?
30) If you're currently using any nutritional supplements, please list them (as well as the doses you're taking) below.

31) Please input what your average daily diet consists of. Be sure that these records are representative of the last few months of your dietary intake. In other words, if you just decided to get in shape two weeks ago and changed your diet dramatically, you should give us an indication of how you had been eating habitually prior to the recent change.

	Daily Diet Log
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Dessert
Night Snack

32) How long have you been eating in the manner recorded on your dietary record? (If your answer is less than one month, please fill out your record according to your prior intake before this recent month
Miscellaneous Information
33) If there is any other information you think relevant to your program design, please share it with us below.
34) Please share your most frequent health, nutrition, or physique complaints and/or dissatisfaction with us.
35)What is your desired goal(s) overall?
36) What is the greatest obstacle you have faced that has prevented you from achieving your goal?
I, Full Name understand that the information collected by Cyber Siren Fitness LLC will be used for fitness evaluation purposes and for the design, implementation, progression, and maintenance of an individualized fitness program only. I further understand that all such information is confidential and will not be shared with anyone without my prior written authorization, except in the case of a medical emergency or to the minimum extent necessary to achieve a safe and effective fitness program.
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Basic Information

Exercise Information

Lifestyle Information

Miscellaneous Information