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Fitness Assessment

Build a complete picture of each client before training starts: personal details, emergency contacts, body measurements, medical background, eating habits and goals. The groundwork for a safe, personalized program.

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Name

First Name

Last Name

Age

Date of birth

Gender

Female Male Prefer not to say

Phone number

Address

Street Address

City

State / Province

ZIP / Postal Code

Occupation

Emergency contact person

First Name

Last Name

Emergency contact phone number

Physician name

First Name

Last Name

Physician phone number

Are you currently following any exercise program?

Yes, a structured program Yes, occasionally No

Height (in)

Weight (lbs)

Body fat %

Do you have any of the following conditions?

Heart disease High blood pressure Diabetes Asthma Joint problems None

Are you a smoker?

Yes No Former smoker

Are you pregnant? (female only)

Yes No Not applicable

Do you drink alcohol?

Regularly Occasionally Never

How many times a day do you exercise?

Do you eat 3 meals a day? (breakfast, lunch, dinner)

Yes, always Most days Rarely

What do you usually eat for breakfast?

What do you usually eat for lunch?

What do you usually eat for dinner?

Are you currently taking medications? If yes, which ones and for what purpose?

Have you had any injuries? If yes, please indicate where

Have you been hospitalized before? If yes, please indicate when and why.

Have you undergone any surgeries? If yes, please indicate the type

What are your goals in this program?

Weight loss Muscle gain Improve endurance Improve flexibility General health

How much time per week can you dedicate to this program?

Client signature

Sign here

Date signed

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