History and Evaluation Assessment
How did you hear about us? ___________________________________
Name: __________________________________________ Date: _____________
Address: ____________________________________________________________
City, State, ZIP: _________________________________________________________
Home Phone: ____________________ Cell phone: _______________________
Age:_______
Date of Birth:________________
*E-Mail:______________________________________________________________
If under 18, please list parent’s name & email:
______________________________________________________________________
Please list the type of training session(s) you are interested in:
i.e Sports Prep, One-on-one, Boot Camp, Small Group Training, other
______________________________________________________________________
Preferred training time(s) _________________________________________
Office Use Only:
Follow up email sent
Start Date Scheduled
Photo Taken
Release Signed
Initial Supplements
_____
Added to in-house email _____
_____
Added to Newsletter
_____
_____
Referral Names
_____
_____ Nutritional Overview Scheduled _____
_____
Added to Volo
_____
Matrix Goal Guarantee:
If you attend all sessions and comply completely with the nutritional
recommendations provided, you will achieve your agreed-upon goal, of
your next month of sessions are free.
What are your goals for this program?
1°_____________________________________________________________________
2°_____________________________________________________________________
Are there any immediate timelines associated with these goals such as tryouts,
important functions, vacations, etc? ____________
If so, please explain: ____________________________________________________
Do you agree with the goals and timelines we have set today? ________________
Signature: _____________________________________________________________
Dietary Adjustments:
If your goal is weight management, you will be asked to follow a specific diet
plan, unless you have a verifiable medical condition which prevents you from
doing this. Do you feel you will be able to comply with this routine? (Y/N) If not,
please explain.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature: ______________________________________________________________
Do you currently smoke? _____ If so, how much? _________________________
Do you consume alcohol? ______ If so, how much and how frequently?
_______________________________________________________________________
Do you have any injuries, conditions or movement limitations that would
prevent you from performing any exercise or activity?
________________________________________________________________________
________________________________________________________________________
Do you currently have, or have you ever been diagnosed with any of the
following:







Hypertension (>140/90)
High Cholesterol
Diabetes
Dizzy Spells
Shortness of Breath
Chest Pain
Family History of Coronary Disease
Have you had a recent physical?
___________
If so, are you cleared for physical activity?
___________
Are you currently involved with any regular recreational activities (golf, clubs,
leagues, etc)? _________ If so, please list:
________________________________________________________________________
____________________________________________________________
How would you describe you current nutritional habits/challenges?
________________________________________________________________________
Please list any food allergies you are aware of:
________________________________________________________________________
Please list any food(s) you will NOT incorporate into your diet. If you do not
list specific foods here, they may appear in your diet plan:
Vegetables: ____________________________________________________________
Meats: ________________________________________________________________
Dairy: ________________________________________________________________
Other: ________________________________________________________________
Do you take an Omega 3 or other “good fat” supplement? _______
If so, please list:
________________________________________________________________________
Do you take a Multi-Vitamin? _______ If so, please list the brand and any
other supplements you may be currently taking:
________________________________________________________________________
________________________________________________________________________
(If possible, please bring the container with you to the next session.)
How many hours of sleep do you get per night?
_________
Is your sleep interrupted regularly for any reason? _________
If “yes”, please explain ________________________________________________
On a Scale of 1 through 10, with 10 being the HIGHEST level, how would you
describe the stress level in your life? ___________________________
Do you have friends, co-workers or family members who might benefit from 2
free weeks here? Persons listed below will receive a gift certificate from you
for our services.
1)______________________________________________________________________
2)______________________________________________________________________
3)______________________________________________________________________
4)______________________________________________________________________
Measurements:
Current
Bodyweight
Target
Bodyweight
Body Fat %
Body Fat %
Waist
Waist
Hip
Hip
Neck
Neck
Biceps
Biceps
Upper Leg
Upper Leg
Male – Optional Chest
Optional Chest - Male
Hip To Waist Ratio –
__________
Client Notes: (Please list any information that would impact client progress. i. e.
Supplements taken/last order date, new injuries, job changes, medical conditions
not covered, etc.)
Use reverse of this sheet if necessary.
________________________________________________________________________
I. Overhead Squat
Initial Test:
Movement Limitation (Circle):
Yes
No
Muscle group Limitation(s):______________________________________________
Follow up #1
Yes
No
Muscle group limitation(s):____________________________________________________________
II. Klatt test
Initial Test
Follow up
Max Height dropped:
_________
_________
Vastus medialis:
________ L_______R
________L ________R
Hamstrings:
________ L_______R
________L ________R
Hip rotators:
________ L_______R
________L ________R
Q-L (General Torso):
________ L_______R
________L ________R
Glutes:
________ L_______R
________L ________R
Adductors
________ L_______ R
________L ________R
Low Back
________ L_______ R
________L ________R
III. McGill Torso Endurance Test:
Initial
Follow up
Left Lateral Side Bridge
_______
_______
Right Lateral Side Bridge
_______
_______
Ratios:
1) Right side : Left Side
Indication of Imbalance
> or - > .05
_______
IV. Vertical Jump _____________
V. Chin Ups (Palms facing) ___________
VI. VO2 Max – Circle one version depending upon facilities available
Beep Test: Level:
______ Cones: ______ Treadmill V02 Max
Projected VO2 Max:
________
Time:_________
VII. Flexibility – Indicate Pass or Fail
(If “Fail”, indicate number of degrees short of ideal)
Follow up
Piriformis:
L________ Target 0°
R________
Actual_______ _______
Actual_______ _______
Medial Hamstrings:
L________ Target > 90° Actual_______ _______
R________
Actual_______ _______
Sagittal Hamstring:
L________ Target > 100°Actual_______ _______
R________
Actual_______ _______
Rectus Femoris:
L________ Target > 90° Actual_______ _______
R________
Actual_______ _______
Quadriceps:
L________ Target 120° Actual_______ _______
R________
Actual_______ _______
TFL (+ or -):
L________
R________
Psoas:
L________ Target -5°
R________
_______
_______
Actual_______ _______
Actual_______ _______
Recommended Lifting Movements: _______________________________________
________________________________________________________________________
________________________________________________________________________
Recommended Pre-workout Activities: _________________________________
________________________________________________________________________
________________________________________________________________________
Recommended Post-workout Flexibility: __________________________________
________________________________________________________________________
________________________________________________________________________
Matrix Strength & Fitness, Inc
.
AGREEMENT
RELEASE FROM LIABILITY
1)
I, ______________________, for good and proper consideration, do hereby freely
and voluntarily acknowledge and appreciate the services and activities I wish to
engage in with Matrix Strength & Fitness, Inc., their employees, servants, agents
and assigns, such as weight training, flexibility and aerobic exercises to include
the use of the various equipment are inherently risky and potentially dangerous
activities. I freely and voluntarily choose to engage in these potentially dangerous
activities and assume and accept any and all risk, including serious injury or even
death. (Please initial________).
2)
I do hereby forever waive, release, absolve, discharge and hold blameless Matrix
Strength & Fitness, Inc., their employees, servants, agents and assigns, from any
and all liability, loss, injury, damage, costs, claims and/or causes of action,
including those caused by the negligent acts or omissions, including but not
limited to the use of equipment at any site including my home, provided by and/or
recommended by said persons or of those acting on their behalf, arising out of my
participation in these dangerous activities. (Please initial______).
3)
I do hereby further declare myself to be physically and mentally sound and
suffering from no condition, disease, infirmity or other illness that would prevent
or impair my participation or use of the equipment. I do hereby acknowledge that
I have discussed my participation in these potentially dangerous activities with a
physician and have been cleared to participate or that I have freely and voluntarily
decided to participate in these potentially dangerous activities without the
approval of a physician and do hereby assume all responsibility for my
participation. I acknowledge that it is recommended that I have yearly or more
frequent examinations and consultations with a physician regarding my
participation in these activities, exercise and use of equipment. I further
acknowledge and understand that Matrix Strength & Fitness, Inc.’s provision and
maintenance of an exercise/fitness program for me does not constitute any
acknowledgment, representation or indication of my physiological well-being or
any medical opinion relating thereto. (Please initial_______).
Understood and agreed to this ________day of ________________________, 20______.
_____________________________
Client’s signature:
______________________________
Authorized representative