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New Client Profile
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Date of Birth
Occupation
Height
Weight
How did you hear about us?
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Date
Name
Address
Phone
Cell Phone
Email Address
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Personal Goals
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Primary Training and Nutrition Objectives (check one or more)
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Strength
Shape & Tone
Reduce Stress
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Weight Loss
Injury Rehabilitation
Cardiovascular Endurance
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Fat Loss
Build Muscle
Sport Specific
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List areas of the body you specifically want to work on
Is there a specific time frame in mind
Training experience
Anything else you would like to discuss about your goals
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Do you currently
have any injuries?
If yes, please explain:
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Please list any health problems you have
or have had that have been diagnosed or
treated by a health professional:
Please list any medications you
may be currently taking:
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How many hours of sleep do you get per day? (average)
Have you ever suffered from insomnia?
How many meals do you eat daily?
Do you eat meat?
Do you snack?
Do you have any dietary restrictions or allergies?
Do you smoke?
Do you ingest alcohol?
Are you currently taking a multivitamin, mineral or any
other type of food supplement?
How much water would you say you drink per day?
What do you eat for breakfast?
Do you have support at home, with friends and/or
family with changes in you lifestyle?
List any foods you do not like or refuse to eat:
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Yes
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No
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Yes
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No
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Favorite food:
Favorite snack:
If yes, what type:
If yes, how much?
If yes, how much?
If yes, what?
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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How many days a week would you like to train?
When would you like to start?
What times and days are best for you to workout?
How flexible is your selected schedule above?
Do you prefer a male or female trainer or doesn't
matter?
Where would you like to train? In home or gym?
When is the best time to contact you?
Do you text message?
Do you check email often?
What form of communication do you prefer?
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Yes
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No
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Yes
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No
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Phone
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Text
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Email
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Any form of communication is fine
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Waiver
By agreeing to this document, I acknowledge that I have voluntarily chosen to participate in a program of
progressive physical exercise which can enhance the musculoskeletal and cardiorespiratory systems. I am
aware of my responsibility to consult with my personal physician regarding my medical fitness to engage in
strenuous exercise and a nutritional support program.
By agreeing to this document, I acknowledge being informed of the possible strenuous nature of the
program and the potential for unusual, but possible, physiological results including, but not limited to,
abnormal blood pressure, fainting, heart attack or death.
By agreeing to this document, I assume all risk for my health and well being and hold harmless of any
responsibility, the instructor (trainer), web site, facility or any persons administering this instrument for
any and all injuries suffered while following the training and/or nutrition program provided to me.
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I Agree
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