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Fit Unlimited Questionnaire

Please fill out prior to booking your Fitness Assessment. This form is mandatory to all our NEW dope clients.

All information received on this questionnaire will be treated as strictly confidential. This information is essential to helping our trainers develop a program that addresses your needs and goals in a safe and effective manner.

First Name

Birthday

Last Name

Email

Code

Phone

Select an Address

Occupation

Choose an option

Emergency Contact Name / Phone

Please indicate if any of these statements apply to you by placing a YES in the space provided (*past or current)

History of heart problems (ie. chest pains, heart murmur, or stroke)

Diabetes Mellitus

Asthma, breathing or lung problems

Allergies

Cancer (other than skin)

Seizures, seizure medication, neurological problems dizziness

High blood pressure

Back problem, joint or muscle disorder still affecting you

Recent surgery (last 12 months)

Hernia or any condition that may be aggravated by exercise

Physician’s advice not to exercise

History of high cholesterol

Family history of coronary heart disease?

Do you smoke tobacco products?

Do you consume alcohol?

Do you take supplements of any kind?

Are you on medication?

Do you have a joint problem that might be aggravated by exercise?

Is stress from daily living an issue in your life?

Any skeletal injuries, issues, or surgeries? (If yes, Please Explain)

What are your top 3 Goals you want to achieve?

From a scale of 1 through 10, 10 being the most important, How important is it for you to reach these goals? Pick one

1

2

3

4

5

6

7

8

9

10

What obstacle(s) might interfere with your goal achievement(s)?

What are your strategies to overcome the obstacle(s)?

How would you describe your level of daily activities?

Light (office work)

Moderate (manual labor)

Heavy (construction)

Number of hours of sleep per night?

What is your available time and frequency for exercise? What days: Mon Tue Wed Thu Fri Sat Sun

Are you currently taking any vitamins or Supplements? (if yes, explain)

Any special considerations or requests?

I agree to the terms & conditions

Thanks for submitting. please Schedule your Assessment session here

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Fit Unlimited Questionnaire

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