PERSONAL DETAILS Full Name Date of Birth E-mail Phone HEALTH & FITNESS GOALS: Please check all that apply. General Health Weight managementLower cholesterolImprove body compositionReduce stressReduce my risk of disease Fitness Increase aerobic capacityIncrease muscular strengthImprove flexibilitySport-specific training Functional Improve balanceImprove postureReduce back painStrengthen core (abs/back)Other Please list any injuries or joint limitations (Include neck, shoulders, hips, knees, low back, etc.): Are you taking any medications? Do you suffer from a heart condition or have ever had any form of heart disease, Previously suffered a heart attack, or have a family history of heart disease? Do you experience any pain while undertaking physical activity or exercise? Have you experienced faintness, dizziness, shortness of breath or experience a loss of balance while undertaking physical activity or exercise? Do you have diabetes or suffer from high blood pressure? Do you suffer from asthma? Past exercise experience: Number of personal training sessions per week: OneTwoThreeFourFive Length of each personal training session: 1⁄2 Hour1 Hour Weekly training days: Early morning (06:30 – 07:30)Mid-morning (08:00 – 11:00)Mid day (11:00 – 14:00)Afternoon (14:00 – 17:00 )Evening (17:00 – 20:00)Late evening (20:00 – 22:00) Please Indicate Preference: Female TrainerMale TrainerNo Preference Preferred Start Date: By using this form you agree with the storage and handling of your data.
