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name ___________________________________________ uC8 __________________ Age _______
Address ___________________________________________________________________________
Lmall_________________________________________________ Moblle______________________
CccupaLlon _____________________________

0,/1# 2 3 0(1.) /.4 0567,-6)
1. Pas your docLor ever Lold you LhaL you have a hearL condlLlon or have you
ever suffered a sLroke?
! ? !n
2. uo you ever experlence unexplalned palns ln your chesL aL resL or durlng
physlcal acLlvlLy/ exerclse?
! ? !n
3. uo you ever feel felnL or have spells of dlzzlness durlng physlcal exerclse
LhaL causes you Lo lose balance?
! ? !n
4. Pave you had an asLhma aLLack LhaL has requlred lmmedlaLe medlcal
aLLenLlon aL any Llme over Lhe lasL 12 monLhs?
! ? !n
3. lf you have dlabeLes (1ype l or 1ype ll) have you had Lrouble conLrolllng
your blood glucose ln Lhe lasL 3 monLhs?
! ? !n
6. uo you have any dlagnosed muscle, bone or [olnL problems LhaL you have
been Lold could be made worse by parLlclpaLlng ln physlcal acLlvlLy/ exerclse?
! ? !n
7. uo you have any medlcal condlLlon(s) LhaL may make lL dangerous for you
Lo parLlclpaLe ln physlcal acLlvlLy/ exerclse?
! ? !n

0,/1# 8 3 9(): ;/',-")
1. uo you have any lmmedlaLe famlly hlsLory of hearL dlsease or sLroke? lf yes, provlde deLalls (who,
Lhelr age and resulL of hearL dlsease or sLroke) ____________

2. uo you smoke? ?es no lf yes, number of clgareLLes per day ______
3. Are you pregnanL? ?es no

4. uescrlbe your currenL physlcal acLlvlLy levels
! vlgorous ! ModeraLe ! LlghL
lrequency ___ x per week uuraLlon ___ mlns per sesslon
3. uo you have hlgh blood pressure ?es no
6. uo you have hlgh cholesLerol ?es no
7. uo you have hlgh blood sugar ?es no

8. Are you currenLly Laklng any prescrlbed medlcaLlon? ?es no
lf yes, whaL ls Lhe medlcaLlon for? ______________________________________________________

9. uo you have any muscle, [olnL, or bone paln LhaL ls made worse by parLlcular Lypes of acLlvlLy?
?es no
lf yes, provlde deLalls ________________________________________________________________



0,/1# < 3 9#)+=,) ,- >'?(#@#
1. WhaL resulLs do you wlsh Lo achleve?
! 8educe body faL ! SLrengLh 1ralnlng ! WelghL Loss
! SLress ManagemenL ! 8eshaplng ! lncrease flLness
! SporLs CondlLlonlng ! lmprove Muscle 1one ! lmprove llexlblllLy
! 8ehablllLaLlon ! lncrease Muscle Mass ! CLher _________________

2. Where do you wanL Lo achleve your resulLs?
! 1hlghs ! 8ack ! Lower 8ack
! SLomach ! Arms ! Plps
! 8uLLocks ! Shoulders ! WalsL
! ChesL ! Calves ! CLher__________________

3. WhaL ls your overall goal? __________________________________________________________
__________________________________________________________________________________
4. When would you llke Lo achleve Lhese resulLs? __________________________________________
__________________________________________________________________________________
3. Why would you llke Lo achleve Lhese resulLs? ___________________________________________
6. Pow many days a week do you wlsh Lo exerclse? ________________________________________
7. Pow long have you been Lhlnklng abouL lL? ____________________________________________
8. WhaL has kepL you from sLarLlng sooner? ______________________________________________
9. Cn a scale from 1 - 10 how lmporLanL ls lL for you Lo achleve your resulLs? 1 2 3 4 3 6 7 8 9 10
10. Why ls lL so lmporLanL for you Lo achleve Lhese resulLs? _________________________________
__________________________________________________________________________________

A/":#,(.1
l agree Lo allow lunk ?our !unk Lo use plcLures, vldeos or Lhe llke for poLenLlal markeLlng maLerlal
Slgned _____________________________________________________ uaLe __________

9#=#/)# -B C(/D(=(,5
l belleve tbot to tbe best of my koowleJqe, oll of tbe lofotmotloo l bove sopplleJ wltblo tbls fotm ls cottect. l
ockoowleJqe tbot l most seek oJvlce ftom my Cl ot ollleJ beoltb cote ptofessloool lf l bove oosweteJ 5 to
ooy of tbese 7 poestloos lo stoqe 1 of tbe fotm, ot two ot mote poestloos lo stoqe 2 pleose seek qolJooce ftom
yoot Cl ot opptoptlote ollleJ beoltb ptofessloool ptlot to ooJettokloq lo pbyslcol octlvlty/ exetclse.

l ooJetstooJ tbot my petsoool ttoloet ls oot oble to ptovlJe me wltb meJlcol oJvlce wltb teqotJ to ooy meJlcol
cooJltloos l moy bove ooJ tbot tbls lofotmotloo ls oseJ ooly os o qolJelloe to tbe llmltotloos of my oblllty to
exetclse. l wlll oot bolJ my petsoool ttoloet lloble lo ooy woy fot ooy lojotles tbot moy occot wblle l om ttololoq.
Slgned _____________________________________________________ uaLe __________
As yoo ote o voloeJ clleot of look oot Iook letsoool 1tololoq, we woolJ llke to qlve yoo tbe oppottoolty to
offet o compllmeototy sessloo to tbtee of yoot ftleoJs, fomlly membets ot co-wotkets. we moy botb be oble to
moke o boqe Jlffeteoce lo tbelt llves. lleose toke tbe tlme to jot Jowo tbe oomes of wbom yoo belleve ote
teoJy to toke octloo ooJ ocbleve tbelt beoltb ooJ fltoess qools.
_________________________ _________________________ _________________________