Springfit Performance Training Form

Name*
First NameLast Name
Email*
example@example.com
Phone Number*
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth*
Emergency Contact Name*
First NameLast Name
Emergency Phone Number*
Area CodePhone Number
Are you currently seeing a Dr. or any other health professional for any reason(s)? If Yes, please describe.
Please list allergies?
Please list medications
Have you exercised in the last 3 months? If Yes, please describe activity briefly.*
Have you had a physical within the last year? Any pending issues?*
Please describe any muscular-skeletal issues that may impede on your participation in our program? (Start with head/neck and go down to ankles/feet)
What are you goals? (Please be specific)*
Are you currently on a diet? If Yes, please describe.
Are you taking any dietary supplements? If Yes, please describe.*
Have you ever had an abnormal EKG, pain radiating down arms or tingling, abnormal heart rhythm, heart murmur, rheumatic fever, pain/discomfort in chest area, difficulty breathing during exercise?
Have you had any history of heart disease, high blood pressure, osteoporosis, arthritis? If Yes, please be specific and explain:
Any members of your family have a history of any of the above? (Mother/Father) If Yes, please describe.
Performance Coach / Sports Medicine Testing Area Only:
Resting Pulse: 1 Resting BP:   2
Body Fat %:   1
Body Fat%   4   Omron Tester:   5
Total Body Weight:   6   Sub-Max VO2-:   7
Max VO2-:   8
ANTHROPOMETRIC MEASUREMENTS

Ch:9 Tri:   9
Ab#1:   11   Ab#2:   12
Hip:   13   Thigh:   14
Max VO2-:   15
Vertical Jump (best of 3):16
Standing Long Jump (best of 3) 16
LX - Plyo 18
Flexibility 119
Flexibility 2 19
Flexibility 3 21
MUSCULAR TESTING (One Minute)
Pushups (modified or regular)22
RGPD (minute) 22
Sit-ups (90 sec Tdown)   24   TriPD: (minute)   25
Side-Side Agility test:   26
How many hours of sleep on average do you get per night?
What are the main contributors to your overall stress?
How much time and what activities do you do to relax?
What is the time frame between your last meal and your bed time?
Do you eat breakfast within 30-60 mins upon waking?
Diet Snapshot
Do you:
Yes No
Drink Coffee Daily
Use Pre-workout more than 1 x per week
Drink alcohol more than once a week
Smoke cigarettes
Drink 3L water per day
Drink soft drink regularly

Please answer the following truthfully

	Confident	Somewhat Confident	Not Confident
Im prepared to track my food intake
Im prepared to fill in my training plan
Im prepared to send progress pictures as specified
Im prepared to fill in my tracking sheet
Im prepared to modify my diet
Im prepared to take supplements as necessary
Im prepared to modify my lifestyle habits

Parent or Self Signature Required (18 years old and up)
Clear
Signature provided by Client
Signature Required (minor under 17 years old)
Clear
Signature provided by Client
Should be Empty:

	Yes	No
Drink Coffee Daily
Use Pre-workout more than 1 x per week
Drink alcohol more than once a week
Smoke cigarettes
Drink 3L water per day
Drink soft drink regularly

Performance Coach / Sports Medicine Testing Area Only: