BODY DEFINITION – DEFINE WHO YOU WANT TO BE
CLIENT SHEET
Name:
Address:
Phone Number:
DOB: Age:
Email:
Emergency Contact Name:
Phone Number:
Relationship:
What services are you most interested in? PLEASE CIRCLE ALL OF INTEREST FOR NOW OR IN
THE FUTURE.
Boot Camp
One on One In Home Personal Training
SPIN Class
Make-up/Make-over Consultation
In Home Group Training (2-4)
Custom Blend Foundation or Powders
Bridal Group Program
Bridal/Special Occasion Make-up
Online Training & Nutrition
Fitness Competition Training
Feel Better Naked Program – Includes 12 week online training and nutrition and at the end of the 12
weeks – boudoir photo shoot with hair and make – up INCLUDED.
Out of an exercise experience what would make the experience a 10 FOR YOU?
List Three GOALS you would like to achieve with an exercise Program:
LIST THREE THINGS you are willing to sacrifice for your goals:
LIST THREE MAJOR OBSATCLES YOU FORSEE getting in the way of reaching your goals or have
gotten in the way in the PAST:
BODY DEFINITION – DEFINE WHO YOU WANT TO BE
PersonalTrainingandBootCampClient
MedicalHealthHistoryForm
Pleaseanswereachquestionbyprintingthenecessaryinformation.Youranswerswillbekeptconfidential.
Client Information and Release Form
Name___________________________________________BirthDate_____________Gender_________
Address________________________________________________________________________________
City__________________________________________State________Zip________________________
PhoneNumber(s)Home___________________Work__________________Cell__________________
E‐mail__________________________________________________________________________________
Incaseofemergency,pleasenotify:
Name___________________________________________Relationship____________________________
Address________________________________________________________________________________
City__________________________________________State________Zip________________________
PhoneNumber(s)___________________Home__________________Work__________________Cell
Pleasenote:Inordertoassistyouinthedevelopmentofarewardingphysicalfitness
program,weneedtohaveyourhonestandaccurateresponses.
GeneralMedicalHistory&Information
Areyouunderthecareofaphysician,chiropractor,orotherhealthcareprofessionalforanyreason?
Ifyes,listreason:
_______________________________________________________________________________________________
Areyouawareofanydiseaseordisorderthatwouldcomplicateyourparticipationinatestingor
exercise
program?
________________________________________________________________________________________
Hasyourdoctorevertoldyouthatyouhaveaboneorjointproblemthathasbeenorcouldbemade
worse
byexercise?
______________________________________________________________________________________
Areyoutakinganymedications?Ifyespleaseindicatethetypeofmedication,dosage,frequencyand
reason(s)fortakingit.______________________________________________________________________________________
Pleaselistanyallergies_________________________________________________________________________________
Hasyourdoctoreversaidyourbloodpressurewastoohigh?__________________________________________
Areyouoverage65?_________________Areyouunaccustomedtovigorousexercise?____________________
Isthereanyreasonnotmentionedherewhyyoushouldnotfollowaregularexerciseprogram?
Ifso,pleaseexplain________________________________________________________________________________
Pleasedescribeanypastorcurrentmusculoskeletalconditionsyouhaveincurredsuchasmusclepulls,
sprains,fractures,surgery,backpain,orgeneraldiscomfort:
Head/Neck_____________________________________________________________________________
UpperBack_____________________________________________________________________________
Shoulder/Clavicle_______________________________________________________________________
Arm/Elbow_____________________________________________________________________________
Wrist/Hand_____________________________________________________________________________
LowerBack_____________________________________________________________________________
Hip/Pelvis______________________________________________________________________________
Thigh/Knee____________________________________________________________________________
LowerLeg/Ankle/Foot_________________________________________________________________________
Pleasecircleanyareasofpain,injury,tension,orrestrictionofmovement.
Haveyourecentlyexperiencedanychestpainassociatedwitheitherexerciseorstress?
Ifso,pleaseexplain________________________________________________________________________________
Doyouhaveafamilyhistoryofanyofthefollowingconditions?
HeartDisease__________HeartAttack__________Hypertension__________Gout__________
AbnormalEKG__________Asthma__________HighCholesterol__________Angina__________
Diabetes__________Otherheartconditions__________
Doyouhaveafamilyhistoryofcardiovasculardisease?Ifso,howmanyoccurrencesandwhat
approximateages?_______________________________________________________________________
Areyouasmoker?Ifso,whatisyoursmokingfrequency?_____________________________________
Areyouonanyspecificfood/nutritionalplanatthistime?_____________________________________
Doyoutakedietarysupplements?Ifyes,pleaselist___________________________________________
________________________________________________________________________________________
Howmanybeveragesdoyouconsumeperdaythatcontainscaffeine?___________________________
Doyouexperienceanyfrequentweightfluctuations?__________________________________________
Haveyouexperiencedarecentweightgainorloss?___________________________________________
Ifyes,listchange___________________________________Overhowlong?_________________________
Youranswerstothesequestionswillbediscussedwithyoupriortoyoursession.ThankYou.
Pleasetakeamomenttocarefullyreadthefollowinginformationandsignwhereindicated.
IunderstandthatthepersonaltrainingIreceiveisprovidedforthepurposeofexerciseinstructionandnutritionguidance.Ifurther
understand
thatpersonaltrainersarenotqualifiedtoperform,diagnose,prescribe,ortreatanyphysicalormentalillness,andthatnothingsaidin
thecourseofthesession(s)givenshouldbeconsideredassuch.Ishouldseeaphysician,chiropractor,registereddietitianorother
qualifiedmedicalspecialistforanymedicalnutritionalconcerns,mentalorphysicalailmentthatIamawareof.IaffirmthatIhavestated
allmyknownmedicalconditions,andansweredallquestionshonestly.Iagreetokeepthepersonaltrainerupdatedastoanychangesin
mymedicalprofile,andunderstandthatthereshallnotbeliabilityonthepersonaltrainer’spartshouldIforgettodoso.
IunderstandthatIhaveenrolledinthepersonalizedhealthandfitnessprogramofferedthroughBodyDefinitionandit’spersonal
trainersandaffiliates.Irecognizethattheprogrammayinvolvestrenuousphysicalactivityincluding,butnotlimitedto,musclestrength
andendurance
training,cardiovascularconditioningandtraining,andothervariousfitnessactivities.IherbyaffirmthatIamingoodphysical
conditionanddonotsufferfromanyknowdisabilityorconditionwhichwouldpreventorlimitmyparticipationinthisexercise
program.IacknowledgethatmyenrollmentandsubsequentparticipationinpurelyvoluntaryandinnowaymandatedbyBody
Definitionandit’spersonaltrainersandaffiliates.
Inconsiderationofmyparticipationinthisprogram,IherebyreleaseBodyDefinitionandit’spersonaltrainersandaffiliatesfromany
claims,demands,andcausesofactionasaresultofmyvoluntaryparticipationandenrollmentoftheprovidedpersonaltrainingservices
and/orexerciseclasses.IfullyunderstandthatImayinjuremyselfasaresultofmyenrollmentandsubsequentparticipationinthis
programandIherebyreleaseBodyDefinitionandit’spersonaltrainersandaffiliatesfromanyliabilitynoworinthefuturefor
conditionsthatI
mayobtain.Theseconditionsmayinclude,butarenotlimitedto,heartattacks,musclestrains,musclepulls,muscletears,broken
bones,shinsplints,heatprostration,injuriestoknees,injuriestoback,injuriestofoot,oranyotherillnessorsorenessthatImayincur,
includingdeath.
IHEREBYAFFIRMTHATIHAVEREADANDFULLYUNDERSTANDTHEABOVESTATEMENTS.
Signature______________________________________________________Date_____________________
Consentforminorsisrequiredpriortofirstsession.
Printedname__________________________________________________________________
ClientProfileQuestionnaire
Current Exercise Information
Pleaseexplainyourcurrentexerciseregimenincludingallstrengthtraining,cardiovasculartraining
orothersportingactivitiesthatyouperform.
DayoftheWeek/Activity/LengthofTime:
Body Type / Activity Level / Goal Information
Whatareyourgoals?(Circlethosethatapply)
BodyFatLoss MuscleGain StrengthProduction IncreaseFlexibility GeneralHealthMaintenance
Howactiveareyouand/orwhatisyourexerciselifestylelike?(Circlethosethatapply)
Sedentary
ModerateExercise CompetitiveExercise Bodybuilding
Doesyourjobrequireyoutobe…..(Circlethosethatapply)
Sedentary
SomewhatActive
Active VeryActive
Pleaseansweryesornotothefollowingquestions:
Isithardforyoutogainweight?
Canyoueatalotandstillnotgainweight?
Doyougainorloseweightaccordingtoyourfluctuationsinactivityandfoodconsumption?
Isithardforyoutoloseweight?
Doyougainweightifyou’renotcarefulaboutfoodintake?
Current Nutritional Consumption
Pleaselistthefoods,beverages,supplementsetcthatyoutakeontheaverageday.
Time/Qty/Food‐Beverage‐Supplement
Food Likes / Dislikes / Restrictions
Pleaselistthefoodsyouprefertoeat.
PleaselistthefoodsyouDONOTprefertoeat.
Pleaselistanyfoodsthatyoumustrestrictforanyreasoni.e.medicaletc.
Haveyoueverbeentoldtofollowaspecificnutritionalplaninthepast?Ifso,pleaseindicatethereasonand
thetypeofplanandwhohadprovideditforyou.
Pleasetakeamomenttocarefullyreadthefollowinginformationandsignwhereindicated.
IampurchasingtheservicesofStephanieVillersandBodyDefinitiontodesignaprogramtoaidin
weightmanagementtoenhancemyfitnessgoals.IwillnotholdStephanieVillersandBodyDefinition
personallyliableforanyproblems,illnessesorinjuriesthatmightoccurduetoasuddenchangeinmyeating
orexercisehabits.Thisprogramdoesnotreplacetheadviceofamedicaldoctor,registereddietitianorother
medicalproviderortreatment.Ihaverevealedanyandallnecessaryinformationaboutmyselftopreventany
possiblecomplicationstoStephanieVillersandBodyDefinition
Signature______________________________________________________Date_____________________
Printedname__________________________________________________________________