• 1. Personal Information:

  • Format: (000) 000-0000.
  • Gender*

  • 2. Goals

    Current Health / Fitness Goals:
  • List your top 3*
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  • 3. Health 

    3.1 Physical Activity Readiness Questionnaire
  • Have your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
  • Do you feel pain in your chest when you do physical activity?*
  • In the past month, have you had chest pain when you were not doing physical activity?*
  • Do you sometimes loose your balance because of dizziness or do you ever loose consciousness?*
  • Do you have any physical problems (for example: back, knee or hip) that could be made worse by a change in your physical activity?*
  • Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
  • Do you know of any other reason why you should not do physical activity?*

  • If you answered “Yes” to one or more of the above questions, you should consult a physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

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  • 3.2 General & Medical Questionnaire

  • Are you Peri- or Post- Menopausal*
  • Do any diseases run in your family?*
  • Are you or have you recently been pregnant?*
  • If "Yes" when:
     - -
  • Are you or have you recently been smoking?*
  • If "Yes" when:
     - -
  • Are you or have you recently been drinking?*
  • If "Yes" when:
     - -
  • Are you experiencing any stresses or motivational problems?*
  • Do you have daily bowel movements?*
  • Your current diet could be best characterized as:*
  • Do you suffer from diabetes, asthma, high or low blood pressure?*

  • 4. Current Condition

    4.1 Activity Levels:
  •

  • 4.2 Life & Lifestyle

  • Which days would you prefer to train?*
  • At what times during the day would you prefer to train?*

  • Self Evaluation

  •

  • 4.3 Nutrition

  •
  • Carb Intake?
  • Protein Intake?
  • Fat Intake?
  • Do you ever track your food intake?
  • Which of these are not present in your diet ?

  • Training Terms and Conditions

  • 1.) CANCELLATIONS

    Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

    2.) LATE ARRIVALS

    Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

    3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

    All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

  • I AGREE TO THE ABOVE TERMS & CONDITIONS!*

  • Liability Waiver

  • I   **   Will not hold Good Energy Fitness/ Stephanie Monique or any other persons and business liable for any injury (physical or emotional) contracted prior, during or after training with Stephanie. I understand that it is up to me to take the necessary safety and health precautions prior, during and after all training sessions.

  • Covid Waiver

  • I   **   Will not hold Good Energy Fitness/ Stephanie Monique or any other persons and business liable for any illness (physical or emotional) contracted prior, during or after training with her. I understand that it is up to me to take the necessary safety and health precautions prior and during all training sessions. I feel unsafe, it is my responsibility decline training.

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