Custom Nutrition Program

NEW CLIENT INFORMATION FORM

Please take time to fill out this form completely and a certified professional trainer will contact you within 24 hours to set up a complimentary, one-hour session in which he or she will design a custom program, an exercise plan, and answer any and all questions you have about your personal fitness goals!

There is absolutely no obligation, and you can also have your body fat measured, your nutrition plan analyzed and train with the trainer for the total feel and experience!! So, hurry and sign up today for you have nothing to lose but weight!!!

Your contact information:

Full name:

Date:

Address:

City

State:

Zip code:

Email address:

Home phone:

Work phone:

Cell phone:

About you:

Sex:

Age:

Height:

Weight:

Occupation:

How did you hear about us:

Questionnaire:

What body parts do you specifically want to focus on?

What are your short and long term health, fitness, and wellness goals?

Do you have any injuries?

If yes, why?

Do you have any chronic pain or muscle stiffness?

If yes, what hurts?

Do you have any medical or health conditions?

If yes, please describe:

Are you on any medications?

If yes, please list them:

Have you ever had physical therapy?

If yes, for what and when?

Have you ever found yourself not seeing results from a previous exercise program?

If yes, why?

Have you ever used a professional trainer?

If yes, how was the experience?