Client Exercise History

Please complete the form below prior to your first appointment. If you need assistance, please let us know. (If you’re having trouble with the online form: you may download and complete this Word version instead)

You must complete all required fields and click the SUBMIT button at the bottom of this form for us to receive. If you miss a required field, it will not submit, and will highlight the missed field in red.
You may use the SAVE & FINISH LATER button at the bottom if you are unable to complete the form in one sitting. When you click the button, you will receive a link to continue later. You can choose to have this link emailed to you.

Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Format: MM/DD/YYYY

Address(Required)

Phone(Required)

Email(Required)

Occupation(Required)

How many hours per week do you work?(Required)

Contact in case of emergency (Name & Phone)(Required)

Married/Single?(Required)

Current Weight(Required)

How long at this weight?(Required)

Height(Required)

Have you ever had a personal trainer before and where?(Required)

What did you like most about working with them?

Describe what you would like to accomplish through your fitness program with me:(Required)

How did you hear about the Center?(Required)

Referral

Internet Search

Flier

Mailer

Other

You selected other. How did you hear about us?(Required)

Aside from technical knowledge and personal attention, what type of motivation do you require and expect from a trainer?(Required)

What can we do together to make your exercise program more enjoyable?(Required)

Do you own any type of exercise equipment? (Please list):(Required)

What are your current leisure activities?(Required)

Would you be interested in learning more about fitness, nutrition and lifestyle weight management through reading, watching a video, or listening to audio?(Required)

Below, rate your exercise level on a scale of 1-5 (5 indicating very strenuous) for each age range through your present age range:

Ages 13-20(Required)

Ages 21-30(Required)

N/A

Ages 31-40(Required)

N/A

Ages 41-50(Required)

N/A

Ages 51-60(Required)

N/A

Ages 61-70(Required)

N/A

Ages 70+(Required)

N/A

Were you (or are you) a high school or college athlete? If yes, please specify:(Required)

Do you have negative feelings toward, or have you ever had any bad experience with a physical activity program? If yes, please explain:(Required)

Below, rate yourself on scale of 1 to 5 (1 indicating the lowest value). Check the appropriate box number that best applies:

Characterize your present athletic ability.(Required)

When you exercise, how important is competition?(Required)

Characterize your present cardiovascular capacity.(Required)

Characterize your present muscular capacity.(Required)

Characterize your present flexibility capacity.(Required)

How much time are you willing to devote to an exercise program? Please indicate minutes per day and how many days per week.(Required)

Are you currently involved in regular endurance (cardiovascular) exercise?(Required)

Yes

You selected Yes. What type(s) of exercise, and how many minutes/day and days/week(Required)

Rate your perception of the exertion of your exercise program

Light

Fairly Light

Somewhat hard

Hard

How long have you been exercising regularly? (Indicate months & years)

What other exercise, sports or recreational activities have you participated in in the last 6 months?(Required)

What other exercise, sports or recreational activities have you participated in in the last 5 years?(Required)

Can you exercise during your work day?(Required)

What types of exercise interests you? (Please check all applicable).(Required)

Walking (treadmill/outdoors)

Running (treadmill/outdoors)

Hiking

Swimming

Tennis

Golf

Cycling

Biking

Spin classes

Rowing

Strength training

Softball/baseball

Martial arts

Tai Chi

Yoga

Stretching

Pilates

Dance exercise

What do you want exercise to do for you?(Required)

Rate each goal as far as an exercise program on a scale of 1-10 with 1 being "not important at all" and 10 being "extremely important".

Improve cardiovascular fitness(Required)

Body-fat weight loss(Required)

Reshape or tone my body(Required)

Build more muscle(Required)

Improve flexibility(Required)

Increase energy level(Required)

Improve performance for a specific sport(Required)

Improve mood and ability to cope with stress(Required)

Feel better/improved health(Required)

Enjoyment(Required)

Anything else I should know about you?

CAPTCHA