Client Profile Name Age Date DOB(Date Of Birth) Cell Phone No. Work Phone No. Email Occupation Address Emergency Contact FITNESS GOALS AND OBJECTIVES: Circle all that apply WEIGHT LOSS FLEXIBILITY REDUCE BODY FAT PHYSICAL STRENGTH REDUCE STRESS OVERALL WELLNESS REHABILITATION HEALTHY HEART SPORT SPECIFIC TRAINING GREATER ENERGY MOTIVATION OTHER Preferred Training Time/Day 1. Has a doctor ever said you have a heart condition and that you should only do physical activity Recommended by a doctor? Yes No 2. Do you experience an irregular or racing heart rate during rest or exercise? Yes No 3. Do you feel pain in your chest when you do physical activity? Yes No 4. Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No 6. Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition? Yes No 7. Do you know of any other reason why you should not do physical activity? Yes No 8. Are you over 65 and not accustomed to vigorous exercise? Yes No 9. Are you diabetic? Yes No 10. Are you pregnant? Yes No Send