Fill out the medical history questionnaire with an online waiver system.

Lifestyle & Medical History Questionnaire
All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop program that addresses your needs, goals and interests and is safe and effective.

Please Enter Date *

Please enter valid date.

First and Last Name: * Please enter your name.

Date of Birth: *

Please enter valid date.

Email: * Please enter your email.

Emergecy Contact? (name, phone number) * Please enter your answer here.

Important factors to consider before undertaking any type of exercise program are as follows:

Are you on any medications? (Please list) Please enter your answer here.

Do you smoke? *

Yes

Please select at least one choice above.

Do you have any physical problems that are of concern to you? Please enter your answer here.

Surgery(s)? if yes, please explain Please enter your answer here.

Goal Setting:

How can I best help you? Please check all that applies.

Lose Body Fat

Develop Muscle Tone

Have Fun

Group Accountability

Start an Exercise Program

Strength Training

Increase Muscle Size

Motivation

Please select at least one choice above.

Other: Please enter your answer here.

In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure all your goals are ‘SMART’.

S = Specific (Provide details, how long, how much etc.)
M = Measurable (How will you measure whether you’ve reached your goals)
A = Attainable (Be realistic, set smaller goals)
R = Rewards-Based (Attach a reward to each goal)
T = Time Frame (Set specific dates for goals)

Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months?

1) Please enter your answer here.

2) Please enter your answer here.

3) Please enter your answer here.

How important is it for you to achieve these goals?

Very

Semi

Not Very

Please select at least one choice above.

How long have you been thinking about achieving these goals? Please enter your answer here.

Where do you rate health in your life?

Low Priority

Medium Priority

High Priority

Please select at least one choice above.

How committed are you to achieving your fitness goals?

Very

Semi

Not Very

Please select at least one choice above.