JMARFITNESS Consultation Form

Full Name*

First NameLast Name
Email
example@example.com
Gender

MaleFemaleOther
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Age*
years
Height (CM)
cm
Weight (KG)
KG
Job title
Whats the activity level at your job?

None(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
If yes please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR	No Specific Time Frame

How often are you willing/able to train a week to reach your goal?
Have you trained with a Personal Trainer before?

YesNo
If yes what kind of training did you do:
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
What is the biggest struggle currently for hitting your goals?

NutritionTraining motivationTraining plan knowledgeAll of the aboveOther
How often do you want to do Personal Training a week?
Please Choose
What day(s) would you prefer to have your personal training sessions?

MondayTuesdayWednesdayThursdayFridaySaturdaySundayNo preference
How did you hear about N10ergy?

Word of mouth (Recommendation)Website searchSocial media (Instagram/Tiktok)Alexander park kit sponsorOther
Should be Empty: