Fitness Assessment Form
Please complete all fields so we can better understand your needs
Client Information
Name
*
First Name
Last Name
Email
*
example@example.com
Telephone
*
Age Group
*
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
+65
Birth Sex
*
Male
Female
Health-Related Questions
Are you currently taking any exercise program?
*
Yes
No
Height (cm)
*
Weight (kg)
*
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
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
Can you specify?
*
How much time in a week can you provide in this program?
*
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Please select a time when we could call you to discuss your application
*
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