Personal Exercise and Nutrition Consultation Questionnaire

Welcome to the Fulsnd Fitness family

Participant Information & Health Declaration
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Emergency Contact

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Height
cm
Weight
KG
Whats the activity level at your job?
Do you follow a regular working schedule, do you work days, afternoon or nights?
Health Screening
Medical Clearance
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)?
Are you currently pregnant?
Are you experiencing any stresses or motivational problems?
Has anyone of your immediate family developed heart disease before the age of 60?
Do any diseases run in your family?
Are you a current cigarette smoker?
Your current diet could be best characterized as:
Physical Readiness: Please confirm the following
What following goals does best fit in with your goals?
Are you currently excersising regulary (at least 3x per week)?
Have you trained with a personal trainer before?
At what times during the day would you prefer to train?
What are your expectations on me as your Personal Trainer?
How often do you want to do Personal Training a week?
Please Choose
PT Package Options
Liability Waiver
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 between 30-60 minutes 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.
Signature
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Welcome to the Fulsnd Fitness family