STEP ONE: COMPREHENSIVE HEALTH AND GOALS ASSESSMENT
Please complete this quick form that helps us understand your body, history, and goals—so everything we recommend is tailored specifically to you, before you even walk through the door.
Full Name
*
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Home Address
Street Address Line 2
Postal / Zip Code
How did you hear about us?
*
Please Select
Email
Event Booth
Facebook
Friend/Referral
Instagram
Internet Search
Rec Center
Trainer
Which location is most convenient for you?
*
Please Select
Bay Village
Broadview Heights
Brook Park
Fairview Park (Gemini Center)
Macedonia
Medina
Mentor
North Olmsted
Reminderville
Solon
Tallmadge
Westlake
In my home
Tell Us About Yourself
We ask these questions to tailor your assessment and training plan to fit your body, your lifestyle, and your needs. Your answers are confidential and help us provide the safest and most effective guidance possible.
Date of Birth
-
Month
-
Day
Year
Height
0 of 15 max characters
Weight
0 of 15 max characters
Describe any physical activity you are currently doing somewhat regularly:
0 of 150 max characters
History of heart problems, chest pain, high bp, or stroke?
Yes
No
Any chronic illness or condition?
Yes
No
Any recent surgeries? (12 months)
Yes
No
Pregnancy? (now or within the last 3 months)
Yes
No
Hernia of any condition aggravated by lifting weights?
Yes
No
Muscle, joint or back disorder or previous injury still affecting you?
Yes
No
List any other medical conditions or information not listed above
Do you have any negative feeling towards, or have had any bad experience with a physical activity program?
Yes
No
What is your comfort level with strength training or resistance training?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How many days a week are you willing to devote to an exercise program?
Please Select
1
2
3
4
5
6
7
What days and times fit your schedule best for training?
What types of exercise have you tried in the past? Check all that apply
Aerobic exercise
Barre
Cardio
Cross-training
Dance
Fitness boot camp
High-intensity interval training
Kickboxing
Pilates
Running
Swimming
Yoga
Aqua Aerobics
Calisthenics
Circuit training
Cycling
Flexibility Training
Group fitness classes
Jumping rope
Organized Sports
Rowing
Strength Training
Walking
Other
Beyond fitness, are you interested in improving any of the following?
Losing weight
Increasing energy
Recovery & healthy aging
Hormone balance
Sleep or stress management
Nutrition support
Overall wellness optimization
Not at this time
Would you like our team to share information about additional wellness services, beyond training, that may support your goals?
Yes
No
List your top 3 health and fitness goals:
*
Please verify that you are human
*
Submit
Should be Empty: