Fitness Assessment Form
Client 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.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
Emergency Contact Person
First Name
Last Name
Phone Number of Emergency Person
*
Format: (000) 000-0000.
Physician Name
*
First Name
Last Name
Physician Phone Number
*
Format: (000) 000-0000.
Health-Related Questions
Are you currently on 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
-
Month
-
Day
Year
Date
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Submit
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