Title Mr Mrs Ms Miss Dr

First Name:

Last Name:

Sreet & number:

Town/City:

Postal Code:

Telephone:

Occupation:

Email:

Date of Birth:

Sex: Male Female

Are you on any medication? Yes No
If yes please list them below

Have you ever had any medical conditions? Yes No
If yes please list them below

What is your blood pressure?

What is your resting heart rate?

Are you pregnant? Yes No

Are you asmatic? Yes No

What is your weight?

What is your height?

Have you exercised in the past?

Give a brief description of your fitness level and body shape?

Are you under any stress? Yes No
If yes what did you do and when

What are your goals? Weight Loss Muscle Gain Fitness

General Questions

How many calories a day do you eat?

How much water a day do you drink?

How much alcohol weekly do you drink?

How many hours of sleep each night do you get?

How many meals a day do you eat?

Do you skip Breakfast? Yes No

How much exercise do you do a week?

How much cardio do you do a week?

Are you taking any supplements? Yes No
If yes what are they?

Which picture best displays your body shape?

Ectomorph Endomorph Mesomorph

What specifically do you want to change about your body?

How did you hear about us? Word of Mouth Search Engine Flyer/Leaflet DW Fitness Gym Trainer Register Personal Trainer Network