Instructions

This is your comprehensive client information sheet, in which we will ask you to provide some relevant personal information. The answers to these questions are essential in order to allow us to design an optimized individual fitness program for you. Please answer all questions in the most accurate manner possible while being as concise as possible.

Disclaimer

Please recognize the fact that it is your responsibility to work directly with your physician before, during, and after seeking fitness consultation. As such, any information provided is not to be followed without the prior approval of your physician. If you choose to use this information without the prior consent of your physician, you are agreeing to accept full responsibility for your decision.

Basic Information
Gender: M F

Body Composition
Please provide the following skinfold measures (in mm):
Please provide the following girth measurements (in or cm):
Goals
Given the following goals, please click and drag the items into order of importance, with the top being most important and bottom being least important:
  • Improved Health
  • Increased Muscle Mass
  • Improved Endurance
  • Fat Loss
  • Increased Strength
  • Increased Power
  • Sport Specific*
  • Weight Gain


Do you have a specific timeline for achieving a specific goal?
Yes No

Which type of progress is more important to you:
Immediate progress that's less easily maintained
Maintainable progress that may not be as rapid
Exercise Information
Rate your ability in the following exercises
(check the box that corresponds with your ability):
Exercises Advanced Intermediate Novice Unfamiliar
Barbell Squats
Barbell Deadlift
Barbell Bench Press
Bent-over Barbell Row
Barbell Shoulder Press
Pull-up
Barbell Hack Squat
Olympic Snatch
Olympic Clean
Are you currently exercising regularly (at least 3x per week)?
Yes No
Medical and Health Information




Lifestyle Information

What is the activity level at your job?
None (seated work only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Does your job involve shift work? Yes No

Are you a primary caregiver for children, individuals with a disability, or an elder relative? Yes No
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly











Miscelaneous Information