Please fill out this form completely, if you are undecided on a question please put "NA" in field.
Remember to answer these questions honestly. It is the only way we can get a true assessment of where you are in order to help you achieve your goals. Thank You!

First & Last Name:
Email Address:
How did you hear about us?
Daytime Phone Number:
Evening Phone Number:
What is your sex? Male Female What is your age?
What is your height? Weight?
Have you ever worked with a Personal Trainer/ Nutritionist? Yes No
Did you receive the results that you were looking for? Yes No
Are you in your desired physical condition? Yes No

What areas of your body do you wish to change and/or what do you wish to accomplish from a structured fitness program?


What was your weight 1 year ago? (Estimate)
Do your clothes from 1 year ago still fit comfortably? Yes No
What do you feel would be your desired healthy body weight?
Do you have the amount of energy needed for your lifestyle? Yes No
Do you have mood swings? Yes No
How many days per week do you currently exercise?
How long have you been exercising CONSISTENTLY? Less than 2 weeks 2-4 Weeks 4-8 Weeks Over 8 Weeks
How many times per week do you do weight training? Cardio?
Are you currently on a diet? Yes No
Have you been on 2 or more different diets in the past 5 years? Yes No
Have you achieved long-term success from the diets that you have been on? Yes No
Do you stop your carbohydrates at any specific time? Yes No If so what time?

Please list any known health problems.
(example: diabetes, heart disease, high blood pressure etc.....)

How much water do you estimate that you drink per day in 8 oz glasses?
How much Alcohol do you consume per week? Drinks

If there is anything that we did not cover that you think that we should know or if you have any specific questions please list below.


Thank you for your cooperation. One of our Qualified/ Certified Personal Trainers/ Nutritionist will be contacting you to give you the results of your evaluation. Thank You!