Bombshell Fitness Start Up Questionnaire

Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Weight*
Autocompleted Address
Do you Exercise Regularly?*
Rate your overall activity level*
Rate your ability to preform cardiovascular exercise*
Rate your experience with exercise*
Where are you interested in training?*

In my homeAt my gymAt the Bombshell Fitness StudioOther
What Equipment do you have Access to?*

DumbbellsBarbellsGym Machines (Nautilus, Precor, Cybex, etc...)CablesResistance BandsBosu BallsKettlebellsTRX (or other suspension trainer)BowflexOther
How frequently do you have time to exercise?*
What days are you available to workout?*
What is your interest in working with a Personal Trainer?*

I am interested in Personal Training sessions online via SkypeI would like to work with a Personal Trainer in my home or at the gymI am interested in a workout and diet programs from my Personal Trainer onlyI am interested in an online fitness training program from my Personal Trainer onlyI am interested in a diet program onlyOther
Any comments about what you would like to see in your training program?
How would you rate your nutrition habits?*
Which do you eat regularly?*
Any comments about your nutrition habits?
What are your goals?*

AppearanceCardiovascular EnduranceFlexibilityHealth (General)Muscular DefinitionMuscular SizeMuscular strength/powerSelf-esteem/confidenceSpeedSports performanceStress reductionToning and shapingWeight lossPosture improvement
What are you other goals? Please elaborate on the above answers.
What is the most important thing you feel your trainer can do to help you acheive your goals?
Medical Screening & Health History

Rows	YES	NO
1) Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?
2) Do you feel pain in your chest when you do physical activity?
3) In the past month, have you had chest pain when doing physical activity?
4) Do you lose your balance because of dizziness or do you ever lose consciousness?
5) Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
6) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7) Do you know of any other reason why you should not be physically active?

Please elaborate on any YES answers
Signature (I have read and understood and agere to all the questions in the questionnaire and terms & conditions)*
Should be Empty:

Medical Screening & Health History