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Health and Fitness Information Form

1. How much time per week can you spend working out? ______hrs.
2. How many days per week can you spend working out? ______
3. Please state your fitness goals. _________________________________________________________

4. Where will you exercise?

5. Do you presently exercise?
If yes. How often?___________________________________________________________________

6. Do you prefer:
Cross training

7. What sports do you play? _____________________________________________________________

8. Do you prefer:
Free weights
No weights or machines

9. What is your current program? _________________________________________________________

To Help understand you and your own personnel health/fitness needs.

Please circle one:


Do you have: (circle all that apply)
High blood pressure?
High blood pressure in the past?
Heart disease?
Heart failure?
Rheumetory Arthritis?
Have you ever had children?
Have you ever had children in the past 6 months?
Have you ever had back, knee or shoulder surgery?
If you answered yes to any surgeries above, please explain _____________________________________

Do you have: (circle all that apply)

Write yes or no next to the below question.

Have you ever had a heart attack?
Broken bones?
Torn muscles or ligaments?
Are you on any medication?
When was your last physical examination?

Please explain any orthopedic problems in full _____________________________________________

I am familiar with most exercise . Yes No
I will most likely be seeking the help of a staff member or trainer at my gym. help show me how to perform some of these exercises. Yes No

Yes No

I am not under any care of a physician of any medical or mental reasons that may hinder my exercise
performance. (any persons that have diabetes, heart disease, pulmonary disease, pregnancy, hypertension,
or any other item including distress must have a doctors release Yes No

It is my understanding and I acknowledge that the presentation is not nor its owners, heirs and shareholders
are not responsible for implementation, supervision or monitoring of this or any other exercise program. I assume
all inherent risks, and since this is a special internet service I have ordered, I am waiving all rights of liability for
any injuries I may sustain, including but not limited to death.

Trainee name:_________________________ Signature:______________________________________

Please answer the following questions with a check in the appropriate box. IMPORTANT:

Respond according to your spontaneous, intuitive reactions, rather than your intellectual beliefs or opinions.

For example, some people enjoy the taste of bacon, but they object to the nitrates, so they don't eat it. Others
like red meat, but they're not sure it's good for them. There are people who love potatoes but stay away from
them in an attempt to lose weight. Your answers should reflect only your body's reaction to the idea of the food
in question. If there is a question that is not applicable, simply go on to the next question.

WEIGHT:_______ SEX: MALE____ FEMALE____

F- S- R For breakfast I prefer eggs, bacon and toast.
F- S- R At a buffet lunch I would choose mostly meats.
F- S- R Bread and cheese taste better than bread and jam.
F- S -R I feel tired and irritable when I miss a meal.
F- S -R I desire between-meal snacks like cheese and nuts.
F- S- R I would choose fatty cuts of meat rather than lean cuts.
F -S- R When I find myself dragging through a day, a substantial meat dinner makes me feel much better.
F- S- R I like to eat olives.
F -S-R I'd like broiled lamb chops for dinner.
F- S- R I eat mustard, catsup or steak sauce with my protein.
F- S- R I must eat three meals a day.
F- S- R I believe I get hypoglycemia.
F- S- R Liver and bacon sound good to me.
F- S- R I get hungry late in the evening.
F S R I have one or more bowel movements every day.
F- S- R I have sudden mid-morning or mid-afternoon drops in my energy level.

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