Level One Fitness Client Assessment Form

Full Name*

First NameLast Name

DOB

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)?*

If yes, please list

Have you ever been diagnosed or treated for any chronic disease including asthma?*

If yes, please list

Are you currently taking any medication?*

If yes, please list

Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?*

If yes, please list

PERSONAL DETAILS

If you have answered YES to any of the above questions, you must obtain a medical clearance prior to carrying out a physical exercise program.

HEALTH RELATED BEHAVIOURS

Do you smoke?*

If yes, how many a day?

Do you drink alcohol regularly?*

If yes, how much per week?

How many times on average do you eat fast food per week?*

How many hours of sleep do you normally get per night?*

PSYCHOLOGICAL

Please rate the following. One star being negative to five stars being positive

I have a positive attitude towards things

My job stresses me out.

I am in the best shape of my life.

I would rate my current health.

I am serious about acheiving my goals

GOALS

Do you have any health related goals (i.e. Lower blood pressure, etc)?*

If yes, please list

Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?*

If yes, please list

Do you have any performance specic goals (i.e. Increase 10km run, increase chest strength, etc.)?*

If yes, please list

Do you wish to achieve any of these goals in a specific time frame?*

If yes, please explain

LIABILITY WAIVER Please read carefully before submitting form.

I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Level One Fitness. Having such knowledge, I hereby release , their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.

Please tick box in agreement to the above liability waiver*

I Agree

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