"Fit-In" :: Form

Name:	Email:
Cell #:	Work #:
Home/Training Address:
Date Of Birth:	Age:	Sex:
Emergency Contact
Name:	Phone #:

To ensure safety and health, please provide the following information:
How often do you participate in physical activity?
Never Rarely Often All the Time
If never, have you in the past? Y N

Have you ever participated in a formal training program? Y N

If you currently exercise, what activities does your workout include?


What are your short-term exercise / health / fitness goals? (now - 3 months)


What are your long-term exercise / health / fitness goals? (3 - 12 months)


How would you describe your daily eating habits?


Are you presently on a diet? Y N
If yes, please describe?

Do you have any physical condition, impairment, or disability that might affect your ability to engage in an exercise program ? Y N
If yes, please explain?

None of the following questions are for diagnostic or treatment.