You’re Name-____________________________
You’re Address__________________________________________________________
__________________________________________________________
Contact number
Landline:__________________
Mobile number:__________________
Emergency number:__________________
Email ID:_______________________________________
Your personal details
Age:_________
Sex: MALE/ FEMALE /OTHER
Location: __________________________________
How many hours do you work?__________________
How many hours do you exercise? ________________
If your above 60 how do you keep yourself active?
_________________________________________
1) Your medical profile
Do you suffer from any of the medical conditions given below?
A) Chronic obesity
B) Hypertension
C) Heart conditions, specify: _______________________
D) Arthritis
E) Any other medical conditions: _____________________________
2) For women:
Do you have children? How many? ______________________
Were the deliveries normal?
Yes/No
When was your last delivery? __________________
Are you breast feeding your child? _______________
Is your mensturational cycle regular? __________________
3)
Are you on any medication? Yes/No
If yes, what is the medicine and what is it for?
_________________________________________________
Your body evaluation
Your height: ________________
Your weight: ________________
Your body fat percentage:_______________
Body measurements: (inch/cm)
MEN:
Mid upper right arm:
Chest nipple line:
Waist:
Hips:
Mid right thighs:
Mid right calves:
WOMEN:
Mid upper arm:
Chest nipple line:
Upper abs:
Waist:
Lower abs:
Hips:
Right thigh:
Right calf:
Your current lifestyle
Do you smoke? Yes/No
Do you consume alcohol? Yes/No
If yes, how much? ______________
Are you veg – non veg? __________________
If you are drinking coffee/tea, how many cups do you drink?
______________
Do you follow regular working/sleeping hours? _______________
Do you feel that your work/personal stress tends to overcome you
emotionally/physically?
__________________________________________________________
__________________________________________________________
Have you tried alternative therapy? ________________________
Have you exercised in the past 1 year? Yes/No
If yes, what workout do you enjoy? Yoga/Aerobics/Strength
Choose as many fitness goals you wish to achieve 
1) Limit strength
2) Starting strength
3) Explosive strength
4) Static strength
5) Dynamic strength
6) Agility
7) Flexibility
8) Strength endurance
9) Local muscular endurance
10)
Cardio muscular endurance
11)
Speed endurance
12)
Muscle mass
13)
Low body fat
14)
Low stress level
15)
Relief from illness
16)
Sculpted figure
Your fitness goals
Why do you wish to achieve these fitness goals?
a) General wellness
b) Body transformation
c) Preparing for an event
d) Improve athletic performance
e) Rehabilitation
If you’re going through rehab for fitness describe your medical
condition:
__________________________________________________________
__________________________________________________________
If you want to improve athletic performance then what do you want to
improve?
a) Agility
b) Strength
c) Speed
Do you wish to workout at gym or home? _________________
Do you wish to avail of alternative therapists? Massage/Yoga/Dry
needling
Any other fitness or health related issues you want to mention?
__________________________________________________________
__________________________________________________________