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Name
Your answer
Email Address
Your answer
Phone
Your answer
Age
Your answer
Location / Colonia
Your answer
Referred by
Your answer
What is your current occupation?
Your answer
Does your occupation require extended periods of sitting?
Yes
No
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?
Yes
No
In the past month, have you had chest pain when you are not performing any physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
Do you know of any other reason why you should not engage in physical activity
Yes
No
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)
Yes
No
Your answer
Have you ever had any surgeries? (If yes, please explain.)
Yes
No
Your answer
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? (If yes, please explain.)
Yes
No
Your answer
Are you currently taking any medication? (If yes, please list.)
Yes
No
Are you looking for in-person or virtual training?
In-Person
Virtual
Do you have any specific scheduling requests?
Example: Workout twice a week with trainer and be given homework for additional workouts on my own.
Your answer
Please explain which sports and activities your participated in as a child.
Your answer
Do you currently workout?
Yes
No
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What gym do you workout at?
Your answer
Total workouts per week?
Your answer
Number of days of strength training per week?
Your answer
Number of days of cardio training per week?
Your answer
On a scale of 1-10, how would you rate your current state of fitness and nutrition?
Very unhealthy
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10
Very healthy
Clear selection
Please explain your answer above.
For example: overweight and diabetic to run triathalons and play with my children.
Your answer
On a scale of 1-10, how would you rate your stress levels (taking into account emotional, physical, chemical well-being)?
Stress free
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2
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5
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9
10
Very Stressed
Clear selection
Please explain your answer above.
For example: Meditate daily and connect often with family and friends to demanding job and currently injured.
Your answer
Your answer
Your answer
Your answer
Your answer
What 1-5 specific wellness goals do you want to work towards during workouts?
For example: increase strength; lose weight; train for a triathalon; learn how to manage my nutrition; learn how to meditate.
Your answer
Your answer
Your answer
Your answer
Your answer
Any additional fitness, lifestyle, and wellness goals?
Your answer
Your answer
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