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 doing an exercise program?
Yes
No
What are your goals in this program?
Weight loss
Gain muscle
Be physically fit
Sport performance
Improve overall health
Other
Height (in)
Weight (lbs)
Body Fat Estimate %
Do you have any of the following conditions?
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
Other
Are you a smoker?
Yes
No
Do you drink alcohol?
Yes
No
Briefly describe your current and/or previous injury history?
Briefly describe your current and/or previous training history?
Do you have any mobility restrictions or physical limitations?
What's your favorite movie? And if you were to hire one actor to play your life story who would it be?
Why do you want to work with me, specifically?
Are you willing to invest $200-400 per month on your health and fitness?
Yes
No
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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