Boxing and Fitness Client Assessment Form

A pre-enrollment assessment for boxing and fitness clients that gathers medical history, lifestyle habits, personal goals, and a signed liability waiver before starting the program.

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Full Name

Nombre

Apellido

Birth Date

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

E-mail

Health 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

Lifestyle Habits

The following questions ask about your daily habits

Please answer honestly so we can design a safe program for you

Do you smoke?

If yes, how many a day?

Do you drink alcohol regularly?

If yes, how much per week?

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

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

Self-Assessment

Rate each statement from 1 (strongly disagree) to 5 (strongly agree)

I have a positive attitude towards things

My job stresses me out.

I am in the best shape of my life.

I would rate my current health.

I am serious about achieving my goals

Goals & Objectives

Do you have any health related goals (i.e. Lower blood pressure, etc)?

If yes, please list

Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?

If yes, please list

Do you have any performance specific goals (i.e. Increase 10km run, increase chest strength, etc.)?

If yes, please list

Do you wish to achieve any of these goals in a specific time frame?

If yes, please explain

Liability Waiver

By signing below, you acknowledge the risks of physical training and release the provider from liability

Please tick box in agreement to the above liability waiver

I agree to the terms above

Boxing and Fitness Client Assessment Form

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