Fitness Assessment Form
Basic Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Occupation
Health-Related Questions
Are you currently going to gym or doing any activity?
Yes
No
Height (ft)
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
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