Fitness Client Registration and Assessment Form

FITNESS FOR ACTIVE AGERS

Client Registration & Assessment Form

Thank you for partnering with us on our fitness journey. Please complete this form and we will be in touch to begin the next steps.

CLIENT PERSONAL INFORMATION

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry (optional)

Phone Number*

Area CodePhone Number

E-mail*

Gender*

Height*

Weight*

Which Fitness Program are you interested in?*

Group Fitness ClassesCustomized PlansBoth

EXERCISE

What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?

How many days per week do you get at least 60 minutes of moderate-intensity exercise?

On a scale of 1 to 5, how important are the following fitness goals to you?

Weight Loss

	1	2	3	4	5

1 is Not Very Important, 5 is Extremely Important

Muscle Gain

	1	2	3	4	5

1 is Not Very Important, 5 is Extremely Important

Sports Performance

	1	2	3	4	5

1 is Not Very Important, 5 is Extremely Important

Health Improvement

	1	2	3	4	5

1 is Not Very Important, 5 is Extremely Important

DIET

On a scale of 1 to 5, do you consider your overall diet to be healthy?

	1	2	3	4	5

1 is Very Unhealthy, 5 is Extremely Healthy

Are you currently following any kind of diet? If so, what diet and for what reason(s)?

How would you rank your daily salt intake: low, medium, or high?

How would you rank your daily sugar intake: low, medium, or high?

How would you rank your daily fat intake: low, medium, or high?

On a scale of 1 to 5, how effectively are you able to control your temptations for junk food?

	1	2	3	4	5

1 is Not Very Effective, 5 is Extremely Effective

How many alcoholic drinks do you consume per week?

How many caffeinated beverages such as coffee, tea, soda, and/or energy drinks do you consume per week?

LIFESTYLE

Do you feel like you get enough sleep and wake up feeling rested each day?

On a scale of 1 to 5, how would you rate your average level of stress?

	1	2	3	4	5

1 is Not High Stress, 5 is Extremely Low Stress

What techniques do you currently use to manage your stress levels?

Do you smoke tobacco or use a vaporizer alternative?

OCCUPATION

What is your occupation?

Does your occupation require extended periods of sitting? (If YES, please explain.)

Does your occupation require repetitive movements? (If YES, please explain.)

Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?

RECREATION

Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.)

Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.)

MEDICAL

Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?*

If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?*

LIABILITY WAIVER

Please read carefully before submitting form.

I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Fitness for Active Agers.

Having such knowledge, I hereby release Fitness for Active Agers, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.

Please click box in agreement to the above liability waiver*

I Agree