Fitness Assessment Form
Client Information
Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Health-Related Questions
Are you currently taking any exercise program?
*
Yes
No
Height (ft)
*
Weight (lbs)
*
Do you have the following conditions?
Arthritis
Asthma
Cardiovascular problems
Hypertension
Bone problems
Respiratory issues
Migraine
N/A
Are you a smoker?
Yes
No
Are you pregnant (Female only)?
Yes
No
Do you drink alcohol?
*
Yes
No
How many times do you currently exercise weekly?
*
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
*
Yes
No
What do you usually eat in breakfast?
*
What do you usually eat in lunch?
*
What do you usually eat in dinner?
*
What are your goals in this program?
*
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
Other
What is your exercise level
*
Beginner
Intermediate
Advanced
Other
How much time in a week can you provide in this program? Ex: (twice a week, 3x a week etc.)
*
How much time would you be able to get in a workout each of these days? ( 1 hour, 1Hr 1/2, 2hrs)
*
Do you understand that this is an online training program only?
Yes
No
Monthly Workout Programs are $120. Weekly Workout Programs are $60. Which would work best for you?
*
Weekly
Monthly
Date Signed
-
Month
-
Day
Year
Date
Submit
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