New Client Assessment Form

New Client Assessment
Name

First NameLast Name
Physical Activity and Medical Questionnaire
Has a doctor ever said you have a heart condition and recommended only medical supervised activity?
Do you ever have chest pain brought on by physical activity?
Do you tend to lose consciousness or fall as a result of dizziness?
Has a doctor ever recommended medication for your blood pressure, cholesterol or a hear condition?
Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
Are you aware of any other physical reason against your exercising without medical supervision?
If you have answered yes to any of the above, please answer the following:
Have you consulted your physician about increasing your physical activity and/or performing a fitness assessment?
If you answered no to the previous question, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?
Please check off any of the following conditions or activities that may affect you:
Have you recently had surgery? If so, please specify if possible.
I certify that these statements are true and correct. I understand that a doctor's note may be requested. If a note is requested, I should not proceed with this workout until the note is received.
Signature

Measurements

Past
Are you currently involved in a fitness program? If so, what is your current program?
What have you done in the past to promote a healthy lifestyle?
What are your primary fitness goals?
What areas of your body would you like to improve the most?
How long have you been thinking about these goals?
Why have you waited?
How high of a priority is reaching your goal?

1

2

3

4

5

1 is Worst, 5 is Best
When would you like seeing your results?
Obstacles
What is your current plan to achieve your goal?
What is the biggest obstacle to your success?
Coaching and Nutrition
Have you ever worked with a personal trainer? If so, were you satisfied with your results?
How can I best help you to reach your goal?
Select what best describes you:
Should be Empty:

New Client Assessment