"Exceed Your Potential!"


Initial Consultation Questionnaire
 

Personal Information   Date:
Last Name: First Name:
Address: City:
State: Zip:
Home Phone: Work Phone:
Cell Phone: E-Mail:
Date of Birth: Age:
       
How do you prefer to be contacted?
How did you hear about us?

Exercise History
Have you exercised previously?  Yes  No
If yes, how long has it been since you have stopped?
What type of exercise or activity were you involved in? 
How many days per week?    How long per session? 

Where do you prefer to exercise?

What did you like most about it? 

What did you like least about it? 

Details:

Exercise Goals and Availability

What are your top three fitness goals? 

Do you have a specific time frame you are looking to achieve these goals in?

How much time are you willing and able to devote to exercise now? minutes  days per week

Where do you plan to exercise?

What type of exercise equipment do you have access to?


Personal Medical History

Physician's Name:
Physician's Address:
Date of Last Doctor's Visit:
Reason for Last Doctor's Visit:
   
Emergency Contact:
Emergency Contact Phone Number:
   
Risk Factors:  
  Smoker Past Present
  Hypertension Past Present
  Elevated Cholesterol Past Present
  Diabetes Past Present
  Type-A Behavior Past Present
  Stress Past Present
  Overweight Past Present
  Underweight Past Present
  Inactivity Past Present
   
Current Health:  
  Medications Yes No    If yes, what type?:
  Heart History: Yes No    If yes, what type?:
  Surgery: Yes No    If yes, what type?:
  Arthritis: Yes No    If yes, what type?:
   
Previous Injuries:  
Neck Problems: Yes No  If yes, provide details:
Shoulder Problems: Yes No  If yes, provide details:
Elbow Problems: Yes No  If yes, provide details:
Wrist Problems: Yes No  If yes, provide details:
Back Problems: Yes No  If yes, provide details:
Hip Problems: Yes No  If yes, provide details:
Knee Problems: Yes No  If yes, provide details:
   

Spinal Trauma   Tendonitis  Bursitis  Broken Bones  Joint Injuries

Details of above:

By checking this box before submitting the form,  I, intending to be legally bound, and recognizing the danger involved in physical exercise, do agree as follows:
In consideration for the services rendered by TODAY! Fitness, LLC.  in the establishment of a personal physical-fitness program for my benefit, I agree to waive any rights, claims, or damages for injuries which may occur as a result of my participation in said fitness/nutrition program.
I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program.
I understand that TODAY! Fitness, LLC. is a personal training company and not a medical doctor, and that they will in fact be relying on my representations and disclosures regarding my health and physical condition.
I also do not hold the aforementioned institutions liable for any personal injuries, bodily injuries, or property damage while going to and from the aforementioned property.

 

     
 

Get Toned!   Get Fit!   Lose Weight!   Feel Great!

 


Personal Training | Nutrition Supplements | Exercise Equipment | Cycling Gear | Health & Fitness Books | Home

2005 TODAY! Fitness, LLC.