Super-Soldier Club Application Form

Super-Soldier Club Application Form

Steven Bennett LLC
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
cm
Weight*
KG
Part 2. Lifestyle Information
What do you do for a living?
Whats the activity level at your job?*

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.:*
Part 3. Medical and health information
If you have any diagnosed health problems list the condition(s).*
If you are on any medications, please list them.*
What additional therapies are being undertaken for the given health problem(s)?*
If you have any injuries, please list them.*
What additional therapies are being undertaken for the given injury?*
Are you experiencing any stresses or motivational problems?*

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?*

YesNo
Do any diseases run in your family?*

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
if yes please list:
Are you a current cigarette smoker?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special dietI don't know
Part 4. Goals
Please rate your readiness for change.*

12345678910
What following goals does best fit in with your goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?*
Why?

TImeline for achieving your goal.*

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?*
Please rate your motivational level to do what it takes for reach your goal.*

12345678910
Are you currently exercising (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
If yes what kind of training did you do:
At what times during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?*
Please Choose
What are your expectations on me as your Personal Trainer?
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please Read The Following 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. Please infom me if you will be running late; I can make adjustments to the schedule.

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!*

YesNo
Should be Empty:

Super-Soldier Club Application Form

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Please Read The Following Terms and Conditions.