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Client application
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Name
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First
Last
Height (inches)
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Weight (lbs)
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Age
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What is your goal?
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Please be specific. If your goal is to lose weight, how much do you want to lose?
What Equipment do you have access to?
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list all equipment you have access to
Why do you want to achieve this goal?
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Be as honest and transparent as possible.
What are your barriers?
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What's holding you back? Time? Accountability? Knowledge? Support? Motivation?
Rate your current motivation on a scale of 1-10
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10 being highly motivated and 1 lacking motivation
Client Readiness for Activity
HAS YOUR DOCTOR EVER SAID THAT YOU HAVE A HEART CONDITION AND THAT YOU SHOULD ONLY PERFORM PHYSICAL ACTIVITY RECOMMENDED BY A DOCTOR?
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Yes
No
DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU PERFORM PHYSICAL ACTIVITY?
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Yes
No
IN THE PAST MONTH, HAVE YOU HAD CHEST PAIN WHEN YOU WERE NOT PERFORMING ANY PHYSICAL ACTIVITY?
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Yes
No
DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS?
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Yes
No
DO YOU HAVE A BONE OR JOINT PROBLEM THAT COULD BE MADE WORSE BY A CHANGE IN YOUR PHYSICAL ACTIVITY?
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Yes
No
IS YOUR DOCTOR CURRENTLY PRESCRIBING ANY MEDICATION FOR YOUR BLOOD PRESSURE OR FOR A HEART CONDITION?
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Yes
No
DO YOU KNOW OF ANY OTHER REASON WHY YOU SHOULD NOT ENGAGE IN PHYSICAL ACTIVITY?
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Yes
No
IF YOU HAVE ANSWERED YES TO ONE OR MORE OF THE ABOVE QUESTIONS, CONSULT YOUR DOCTOR BEFORE ENGAGING IN PHYSICAL ACTIVITY. TELL YOUR DOCTOR WHICH QUESTIONS YOU ANSWERED YES TO. AFTER MEDICAL EVALUATION, SEEK ADVICE FROM YOUR DOCTOR ON WHAT TYPE OF ACTIVITY IS SUITABLE FOR YOUR CURRENT CONDITION.
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I understand
General & Medical History
Medical
HAVE YOU EVER HAD ANY INJURIES OR CHRONIC PAIN?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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HAVE YOU EVER HAD ANY SURGERIES?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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HAS A MEDICAL DOCTOR EVER DIAGNOSED YOU WITH A CHRONIC DISEASE, SUCH AS HEART DISEASE, HYPERTENSION, HIGH CHOLESTEROL, OR DIABETES?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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ARE YOU CURRENTLY TAKING ANY MEDICATION?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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Additional Information
IS THERE ANY ELSE YOU THINK I MAY NEED TO KNOW THAT MAY EFFECT YOUR ABILITY TO TRAIN. (THIS IS OF COURSE IN TOTAL CONFIDENCE).
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Is there anything else you think I may need to know about your fitness goals?
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Client Agreement
IF YOU DO NOT COMPLETE YOUR PROGRAMMED SESSION YOU WILL BE CHARGED FOR THAT SESSION. ALL SESSIONS MUST BE PAID FOR IN ADVANCE.
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I understand
I HAVE AGREED TO UNDERTAKE IN A PROGRAM OF PHYSICAL EXERCISE UNDER THE INSTRUCTION OF ERIC STARK FROM 12:12 FITNESS. TRAINING MAY INCLUDE, BUT IS NOT LIMITED TO, WEIGHT AND/OR RESISTANCE TRAINING, CARDIOVASCULAR TRAINING, AND FLOOR MAT EXERCISES. ERIC STARK FROM 12:12 FITNESS AGREES TO INSTRUCT, ASSIST IN THE TRAINING PROCESS. I REALIZE THAT A LARGE PORTION OF MY SUCCESS WILL BE BASED ON MY COMMITMENT TO FOLLOW INSTRUCTION, CHANGING MY LIFESTYLE, AND MY CONSISTENCY WITH MY EXERCISE PROGRAM. 12:12 FITNESS CANNOT GUARANTEE RESULTS, BUT MY WILLINGNESS TO WORK HARD WILL IMPROVE THE OPPORTUNITY OF SUCCESS. I HAVE READ THE ABOVE POLICY AND AGREE TO ITS TERMS AS IT APPLIES TO MY INDIVIDUAL PERSONAL TRAINING PACKAGE.
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I agree
BY CLICKING ‘I AGREE’ & SUBMITTING THIS COMPLETED FORM, YOU CONFIRM THAT YOU HAVE READ, UNDERSTOOD AND COMPLETED THE PAR QUESTIONNAIRE AND ANSWERED ALL QUESTIONS TRUTHFULLY, TO THE BEST OF YOUR KNOWLEDGE.
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I agree
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Individual
Corporate
Content Corner
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