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Fitness Questionnaire

Please complete this fitness questionnaire so that I may gather information to provide you your Custom Personal Workout Program.
PERSONAL INFORMATION:
First Name                                                    Last Name
               
Address
City                                                   State                 Zip
                            
Email Address
Home Phone
Cell Phone
Work Phone
Age           Sex                      Height                       Weight                Frame Size
                ft in         lbs        
MEDICAL HISTORY:  (Check all that apply)
Arthritis Asthma, emphysema, bronchitis
Back Pain High blood pressure
Knee or other joint pain Coronary Disease
Shin Splints Heart Disease
Foot Pain Any known heart problems
Muscle Pain Stroke
Other Pain Epilepsy
Light-headedness or Fainting Are you diabetic
Chest pain at rest or exertion Hypoglycemia
Shortness of Breath Are you pregnant
Hernia Family History of Coronary disease before 55
Do you smoke or use tobacco History of Atherosclerotic disease before 55
Elevated Triglyceride Levels Surgeries, Hospitalization
Elevated Cholesterol (Indicate Level in space below
List current medications
Additional Notes:
WORKOUT HISTORY/GOALS:
How many day per week are you exercising? How long do your workouts usually last?
None up to 30 minutes
1-2 days per week up to 45 minutes
3-4 days per week up to 1 hour
5 or more days per week more than 1 hour
What is your primary Fitness Goal? What is your secondary Fitness Goal?
Lose weight Lose weight
Tone/sculpt Tone/sculpt
Increase muscle strength Increase muscle strength
Flexibility Flexibility
What is your desired weight? lbs.
Are there any body parts you would like to focus on? 
What days per week are you able to work out? (Check all that apply.)
Monday                    Tuesday Wednesday                  Thursday
Friday                       Saturday Sunday
CONSENT FORM:
By accepting this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. In accepting this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death. I also understand that I may stop any training session at anytime. By accepting this document, I assume all risk for my health and well being and any resultant injury or mishap that may affect my well being or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures. 
I understand and accept this document
Press "Submit Form" when you are done. 

 

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