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Fitness Level Questionnaire and Goals
Name - ____________________________ Birthdate - ____________Sex - (M / F)
Address - _________________________ City -__________________ St__________Zip___________
Phone (H) - ___________________ (W) -_________________
Email Address - __________________________
Goals
Beginning Goal
Weight - ________ _______/_________
Body fat % - ________ _______/_________
Pushups* - ________ _______/_________
Situps * - ________ _______/_________
Pullups - ________ _______/_________
Dips - ________ _______/_________
1 mile run - ________ _______/_________
1.5mile run ________ _______/_________
500yd swim - ________ _______/_________
_________ - ________ _______/_________
other
(*maximum or in 2:00 max
time)
Other Goals -
____________________________________________________________________
Join the military, fire / police
department, government agency - By what date___________
If YES - Which
agency-___________________________
What
types of equipment do you have access to?
Full
Gym_____ Swimming
pool___ 400m
track___ Free
weights____ Pullup/Dip
Bars___
Others____________________________________________________________________________
How
much time everyday do you have to exercise?_____ What are your best
Days-off?______ /
_______
(1-2 per week)
Health History
1. Have you had or do you have any disorders mentioned below? (Y/N)
____Heart Disease ____Chest Pains
____Heart Problems____Back Trouble IF YES - PLEASE ELABORATE:
____Anemia ____Asthma
_________________________
____Diabetes ____Hernia
_________________________
____Joint Pain ____Epilepsy
_________________________
____Fainting Spells ____High Blood Pressure _________________________
2. Any history of hospitalizations, operations and/or serious injuries?_____________
____________________________________________________________________
3. Are you currently taking any medications? Please provide specifics.___________ ____________________________________________________________________
By signing I am verifying that the above information is accurate and agree to waive any liability, claims, actions or damage of any kind resulting in the participation in personal training program by Stew Smith. I, ________________________ assume any risks in this program.
_________________________
signature (if minor must be signed by parent)
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