Fitness Consultation 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
*
Occupation
Health-Related Questions
Do you have the following conditions? Select all that apply.
*
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Glaucoma
Bone problems
Respiratory issues
Migraine
Shortness of Breathe
Heart Condition
High Blood Pressure
NONE
Other
If you checked any of the above, please explain.
Have you had any of the following?
*
TIA (mini Stroke)
SVA (Stroke)
Pacemaker
Joint Replacement
Spinal Disk Replacement
NONE
Other
If you checked any of the above, please explain.
Do you have any problems with the following areas? Select all that apply.
*
Knee
Shoulder
Back
Neck
Foot/Ankle
Other
NONE
If you checked any of the above, please explain. (surgeries, injuries, limitations?)
Have you been cleared by a Doctor to workout?
*
YES
NO
Are you a smoker?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Are you pregnant (Female only)?
Yes
No
How many times a week do you CURRENTLY exercise?
*
How many times a week do you WANT to exercise?
*
How many meals do you eat a day?
*
Are you currently taking medications and/or supplements? If yes, what are the medications/supplements and for what purpose?
What are your fitness goals? Select all that apply.
*
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
Other
If other, please explain
Have you ever worked with a Personal Trainer?
*
YES
NO
If yes, please explain.
Have you ever taken part in Group Fitness Training before?
*
YES
NO
If yes, please explain.
What best describes you?
*
I am self motivated and will rock this working out thing on my own!
I want this badly, but definitely need accountability and push!
I want to do this on my own, but don't know the best way to start.
I am clueless:(
How confident do you feel in the gym on your own?
Very Confident
Somewhat Confident
Very unconfident
Which best describes your understanding of correct exercise form for both machines and free weights:
*
I know how to properly execute exercises without hurting myself.
I have some idea but not fully confident.
I've seen others do it, but not too sure how to do it myself.
I have no clue what I am doing.
What is your preferred training style? (Select ALL that apply)
*
Weightlifting / Strength Training
Cardiovascular (Running, Cycling, etc)
High-Intensity Interval Training (HIIT)
Functional Training
Machines
Classes (Yoga, Pilates, Spin, Aerobics)
Mobility / Flexibility / Stretching
Other
How many meals do you eat out per week?
*
How often do you eat fast food per week?
*
How many home cooked meals do you eat per week?
*
Do you meal prep?
*
Yes
No
Sometimes
Is there anything else we need to know?
Client Signature
Date Signed
-
Month
-
Day
Year
Date
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