Client Exercise History Form | MedFit at Gratitude Ranch

Full Name

Date of Birth

Address

Phone

Email Address

Occupation

How many hours per week do you work?

Contact in case of emergency (Name & Phone)

Married/Single?

Current Weight

How long at this weight?

Height

Have you ever had a personal trainer before?

Yes

No

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

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

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

Do you own any type of exercise equipment? (If yes, please list):

What are your current leisure activities?

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

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

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

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

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

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

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

Yes

No

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?

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

Can you exercise during your work day?

What do you want exercise to do for you?

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".

Anything else I should know about you?