Fitness Assessment Form
Client Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Age
Gender
Male
Female
Are you currently using any exercise program?
Yes
No
Height (in)
Weight (lbs)
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 week?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
What do you usually eat in a day?
Health Information
Are you currently taking medications? If yes, will they have an affect on your increased daily activity?
Have you had any injuries in your body? If yes, please indicate the location & time injury took place.
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 muscle
Be physically fit
Sport performance
Improve overall health
Other
How much time per week can you dedicate to your new, healthier lifestyle?
When it comes to your nutrition, what are your weaknesses?
When it comes to your nutrition, what are your strengths?
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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