Active With Ash

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Gender

Date of Birth

MonthDayYear

Age

years

Height

FT'INCHES

Weight

LBS

What do you do for a living?

Whats the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

Please list the physical activities that you participate in outside of the gym and outside of work.:

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.

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

if yes please list:

Are you a current cigarette smoker?

Your current diet could be best characterized as:

Please rate your readiness for change.

What following goals does best fit in with your goals?

How often are you willing to train a week to reach your goal?

(1-7 days a week)

Please rate your motivational level to do what it takes for reach your goal.

Are you currently excersising regulary (at least 3x per week)?

Have you trained with a personal trainer before?

If yes what kind of training did you do:

At what times during the day would you prefer to train?

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 forfeited and cannot be made up on a later date.

2.) LATE ARRIVALS

Each session is 1hour in length. Sessions will not be extended (unless time is available) due to the tardiness 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!