Full Name
*
First Name
Last Name
Gender
*
Male
Female
Other
Email Address
*
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
*
Years
Phone Number
*
Address
What do you do for a living?
What is the activity level of your occupation
None (seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you follow a regular work/study schedule? Briefly outline your schedule
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly
Please list any physical activities that you participate in outside of the gym and outside of work:
Do you have any family history of chronic disease (heart disease, diabetes, etc)?
*
Yes
No
If yes, please list
Do you have any current/past injuries that impact you?
*
Yes
No
If yes, please list
Have you ever been diagnosed or treated for any chronic disease including asthma?
*
Yes
No
If yes, please list
Are you currently taking any medication?
*
Yes
No
If yes, please list
Do you smoke?
Yes
No
If yes, how many per day?
Do you drink alcohol regularly?
Yes
No
If yes, how many standard drinks (roughly) per week?
On average, how many hours of sleep do you get per night?
0-3
4-6
7-8
8-10+
How many times on average do you eat fast food per week?
1-2
3-4
5-7
I generally have a positive attitude towards things
1
2
3
4
5
My job stresses me out
1
2
3
4
5
I am in the best shape of my life
1
2
3
4
5
I would rate my current health
1
2
3
4
5
I am serious about achieving my goals
1
2
3
4
5
Do you have any health related goals (lower blood pressure, improve overall health etc) ?
Yes
No
If yes, please list
Do you have any specific goals relating to body composition (muscle gain, weight loss etc) ?
Yes
No
If yes, please list
Do you have any performance related goals (increase barbell squat, improve cardiovascular endurance etc) ?
Yes
No
If yes, please list
Do you have a timeframe in mind for achieving these goals?
Yes
No
If yes, please explain
Do you consent to photo and video content of you to be posted on social media for business marketing purposes?
Yes
No
How much are you willing to invest per week into personal training services for your health and fitness?
$30 - $50
$50 - $80
$80 - $100
$100 - $200
$200+
CANCELLATION POLICY - If a session is cancelled by the client within 24 hours of the scheduled session time, the client will be charged in full for the session.
*
Yes
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 HL Fitness. Having such knowledge, I hereby release HL Fitness, 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 any said fitness program.*
*
Yes
Submit
Should be Empty: