Thrive Sport and Fitness Solutions Client Assessment Form

Full Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

example@example.com

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)?

If yes, please list

Have you ever been diagnosed or treated for any chronic disease including asthma?

If yes, please list

Are you currently taking any medication?

If yes, please list

Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?

If yes, please list

PERSONAL DETAILS

If you have awnsered yes to any of the above questions are you and your doctor ok with you participating in a exercising strength training program.

HEALTH RELATED BEHAVIOURS

Do you smoke?

If yes, how much?

Do you drink alcohol?

If yes, how often and how much

How many times on average do you eat fast food per week?

How many hours of sleep do you normally get per night?

PSYCHOLOGICAL

Please rate the following. Five stars for the best .

How is my attitude?

How is my stress level each day?

What is my current level of health?

How important are my dreams and desires?

Objectives

What is a compelling desire you have in regards to your sport, health, and fitness?

Do you have specific goals related to changing body composition, weight loss, or building muscle?

If yes, please explain.

At what age did you look and feel your best?

What was your average day like then?

What pain or discomfort do you wish to eradicate or avoid?

What is your biggest obstacle in reaching your dream or desire?

What do you fear about your health & wellness moving into the future?

In your sport on a scale of 1 - 10 (1 being best), where do you see yourself?

LIABILITY WAIVER

Please read carefully before submitting form.

I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Fearless Boxing & Fitness.

Having such knowledge, I hereby release Fearless Boxing & Fitness, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.

Please tick box in agreement to the above liability waiver

LIABILITY WAIVER

Please read carefully before submitting form.

THRIVE SPORT & FITNESS SOLUTIONS CLIENT ASSESSMENT