Fitness Assessment Form
February Daily Habits
Client Information
Name
First Name
Last Name
Age
Date of Birth
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Month
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Day
Year
Date
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February 28 day fitness habit
$97.00 CAD
$
97.00
CAD
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Item subtotal:
$0.00 CAD
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0.00
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Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Health-Related Questions
Are you currently taking any exercise program?
Yes
No
Height (in)
Weight (lbs)
BMI
Body Fat %
Do you have the following conditions?
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
Other
Are you a smoker?
Yes
No
Are you pregnant (Female only)?
Yes
No
Do you drink alcohol?
Yes
No
How many times do you exercise in a day?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
What do you usually eat in breakfast?
What do you usually eat in lunch?
What do you usually eat in dinner?
Are you currently taking medications? If yes, what are the medications and for what purpose?
Have you had any injuries in your body? If yes, please indicate the location
Have you been previously hospitalized? If yes, please indicate when and why.
Did you undergo any surgeries in the past? If yes, please indicate the type of surgery
What are your goals in this program?
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
How much time in a week can you provide in this program?
Client Signature
Date Signed
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Month
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Day
Year
Date
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