To design a customized, safe, and effective training and lifestyle program, please fill out this form as accurately as possible. All information remains confidential.
Page 1
Full Name*
Date of Birth*
Phone Number*
Email Address*
Occupation
Current Weight / Height
What are your primary fitness goals? (Check all that apply)
Please list your top 3 specific goals for the next 90 days
On a scale of 1–10, how committed are you to achieving these goals?
What obstacles or factors have held you back from reaching your goals in the past?
Current Physical Activity Level
How many days per week can you realistically commit to training?
Average hours of sleep per night
How would you rate your current dietary habits?
Are you currently following a specific diet? (e.g., Keto, Vegan, Caloric Deficit, etc.)
What is your biggest nutritional hurdle? (e.g., late-night snacking, skipping meals, time constraint)
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not engage in physical activity?
If you answered YES to any of the questions above, a formal medical clearance from your general practitioner or physician is strongly required before initializing any structured physical exercise programs.
Client Name*
Client Signature*
Date*
Made with eformly · Build free forms online