*Name:
Age:
*Email:
*Phone:
Occupation:
Address:
Do you currently exercise?
Yes
No
If
Yes
:
What type of exercise?
How many times per week?
How long for?
If
No
:
Have you exercised in the past?
Yes
No
If yes, what type?
How long ago?
How many times per week?
How long did you stick with it?
Why did you stop?
Do you or have you suffered from:
Arthritis
Asthma
Diabetes
Heart Condition
Blood Pressure
Muscular/Joint Pain
Neck/Back Pain
Other
Details:
Any other injuries or medical considerations?
Do you smoke?
Yes
No
Are you pregnant or have you recently given birth?
Yes
No
Goals:
Muscle Tone
Reduce Stress
Increase Strength
Endurance
Weight Loss
Injury Rehab
Posture Correction
Speed
Increase Self Esteem
More Energy
Aerobic Fitness
Power
Increase Flexibility
Increase Muscle Mass
Sport Specific
Other:
Do you have any friends or family that may be interested in training?
Yes
No
Would you like to be contacted before each session?
Yes
No
If yes,
Email
Phone
Text Message
Preferred time and day?
