• Gender*
  • Whats the activity level at your job?*

  • 1. General State of Health

    Please be honest, as this information is quite crucial!
  • 1. Has your doctor ever said you have a heart condition, high blood pressure, or any condition requiring supervised physical activity?*
  • 2. Do you feel chest pain, dizziness, or loss of balance during physical activity?*
  • 3. Have you ever fainted or lost consciousness, and is this a frequent occurrence?*
  • 4. Do you feel chest pain, dizziness, or loss of balance during physical activity?*

  • If you answered “YES” to any question, please make sure to provide adequate detail and know that you may be asked to obtain medical clearance prior to exercise. 

  • 2. Pains, Aches, Injuries

  • 1. Do you currently experience pain, discomfort, or movement limitations?*
  • 2. Have you ever had any of the following?*
  • 4. Joint-by-joint - please tick any that cause you problems.*
  • 6. Do you have any movements that you absolutely hate, or won't do?*

  • Lifestyle and fitness

  • 2. Are you a current cigarette smoker?*
  • 3. Your current diet could be best characterized as:*
  • 5. Please rate your readiness for change.*
  • 6. What following goals does best fit in with your goals?*
  • 9. TImeline for achieving your goal.*
    Rows
  • 11. Are you currently excersising regulary (at least 3x per week)?*
  • 12. Have you trained with a personal trainer before?*

  • 1.) CANCELLATIONS

    Cancellations should be made at least 12 hours in advance of a scheduled session. Sessions cancelled less than 12 hours in advance will be charged in full to the client.

    2.) LATE ARRIVALS

    Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

    3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

    All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

  • I AGREE TO THE ABOVE TERMS & CONDITIONS!
  • Today's date
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    2 digit month, 2 digit day, 4 digit year
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