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
*
-
Area Code
Phone Number
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
-
Area Code
Phone Number
Physician Name
First Name
Last Name
Physician Phone Number
*
-
Area Code
Phone Number
How did you hear about us? Referral?
*
-
Name
Social platform
How soon are you ready to start your fitness journey?
*
Please Select
Tomorrow
Next Week
Next Month
Health-Related Questions
Are you currently taking 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?
What is your favorite type of gifts to receive? What is your favorite clothing brand? At certain milestones we like to reward our clients for hitting goals, winning contest etc.
You understand that you are required to keep your card on file for monthly membership to be paid on time.
*
Yes
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Membership Plans
*
prev
next
( X )
Just getting started (entry level)
$150.00
$
150.00
This membership is for clients looking to get back healthy but don't have a very flexible lifestyle time wise or financially. This package includes training once per week for 30-60 mins per session.
Quantity
1
2
3
4
5
6
7
8
9
10
I'm ready!
$300.00
$
300.00
This membership is for clients with fitness experience. You've worked out before and fell off for whatever reason. Now you're ready to dive in again. You have time flexibility to train 2 days per week for 30-45 mins.
Quantity
1
2
3
4
5
6
7
8
9
10
Let's go all in!
$600.00
$
600.00
This membership is for clients that know without doubt the mission they are on to achieve their fitness goals. Financially you are prepared to invest in your health and wellness. You also have time to invest 3 days per week into 30-45 min training sessions. This also includes 1 complimentary swedish massage or 30 min non-invasive lipo body contouring session.
Quantity
1
2
3
4
5
6
7
8
9
10
Group Fitness Monthly
$50.00
$
50.00
Do you want to work out but love a fun class of like-minded fitness buddies? Well this is for you! The best deal is always paying monthly rather than per class. Classes are every Saturday at 12:30pm.
Quantity
1
2
3
4
5
6
7
8
9
10
Group Fitness Daily Pass
$10.00
$
10.00
Do you want to work out but love a fun class of like-minded fitness buddies? Well this is for you! The best deal is always paying monthly rather than per class. Classes are every Saturday at 12:30pm.
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$0.00
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
What is the monthly amount you are willing to invest in your fitness?
Submit
Submit
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