Full Name:
*
Email address
*
Address:
*
Contact Number:
*
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Age:
*
Emergency Contact Person & Contact Number
*
Marital Status
Single
Married/ Relationship
Divorced/ Separated
Kids
Yes
No
How much alcohol do you consume weekly?
1-2 glasses
3-4 glasses
5+ glasses
None
On average how much sleep do you get a night?
Less than 5 hours
5-6 hours
7-8 hours
9+ hours
MEDICAL HISTORY
injuries, movement restrictions, surgeries etc
Have you recently had a medical check up?
*
Yes
No
Maybe
Are you currently on any medication? If yes, what is it and what is it for?
*
Yes
No
If yes what is it & what is it for?
Are you currently pregnant or recently given birth?
*
Yes
No
Maybe
Are you a smoker or ever smoked?
Yes
No
Have you ever had surgery
*
Yes
No
If yes, when and what for?
Do you have any physical conditions or movement restrictions that may affect your training?
*
Yes
No
If yes, please give details
Are you currently exercising?
*
Yes
No
Maybe
If yes, what are you doing?
Are you seeing a physician or health professional?
*
Yes
No
If yes, what for and who are you seeing
Have you been advised by a health professional to undertake an exercise program?
*
Yes
No
Have you been advised by a health professional to AVOID or INCLUDE any particular exercise?
*
Yes
No
If yes, please explain in more detail
Do you have any of the following MEDICAL CONDITIONS?
*
Rows
Yes
No
Asthma
1
2
Arthritis
3
4
Diabetes
5
6
Migraine
7
8
Light Headedness/ Dizziness
9
10
High/ Low Blood Pressure
11
12
High Cholesterol
13
14
Kidney Problems
15
16
Heart Attack
17
18
Stroke
19
20
Chest Pains
21
22
Respiratory Disorders
23
24
Vestibular Problems
25
26
Any Neuromuscular Disease
27
28
Swollen Joints
29
30
Broken Bone/ Dislocated Joint
31
32
Muscular Injury (Sprain)
33
34
Back/ Neck Injury Pain
35
36
Other than previously stated, Is there anything else you can think of that may affect your training in any way?
ACTIVITY / EXERCISE HISTORY
whats your experience in a gym and/ or with training
List your experience with exercise over the past 5 yrs?
*
Have you had a PT before?
*
If yes, did you get the results you wanted?
How would you rate your experience with PT
1
2
3
4
5
FITNESS GOALS
What is your number 1 reason for contacting us?
*
Weight loss
Toning
Build Strength
Endurance
General fitness
Aesthetics
Medical reasons
Social
Sport specific
flexibility
Based on your selection above, please give a short description of what you believe your selection is and entails
*
If i asked you to look at yourself in the mirror right now, what do you see?
What is the time frame for achieving these goals? Is there something important coming up eg: birthday, anniversary etc
On a scale of 1-10 how important is reaching your goal to you?
*
1
2
3
4
5
6
7
8
9
10
What do you think will be your biggest obstacles when reaching your goals?
Motivation
Time
Knowledge
Other
If other, please give a short description
What do you want the most from these sessions?
*
Do you have a weekly budget you are willing to invest in helping you achieve these goals?
Rows
yes
$0-$50
37
$51-$100
38
$101-$200
39
$200+
40
NUTRITION
Do you need help with nutrition?
Yes
No
Maybe
List what you typically eat for breakfast?
List what you typically have for dinner?
List what you typically eat for lunch?
List what you typically snack on between meals?
Please feel free to jot down anything else you think i may of forgotten that could benefit you & getting you to your goals quickly and safely
Submit
Should be Empty: