TODAY! Fitness - Initial Consultation Questionnaire


	"Exceed Your Potential!"

Initial Consultation Questionnaire

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Personal Information		Date:
Last Name:		First Name:
Address:		City:
State:		Zip:
Home Phone:		Work Phone:
Cell Phone:		E-Mail:
Date of Birth:		Age:

How do you prefer to be contacted?
How did you hear about us?

Exercise History
Have you exercised previously? Yes No
If yes, how long has it been since you have stopped?
What type of exercise or activity were you involved in?
How many days per week? How long per session?

Where do you prefer to exercise?

What did you like most about it?

What did you like least about it?

Details:

Exercise Goals and Availability

What are your top three fitness goals?

Do you have a specific time frame you are looking to achieve these goals in?

How much time are you willing and able to devote to exercise now? minutes days per week

Where do you plan to exercise?

What type of exercise equipment do you have access to?

Personal Medical History

Physician's Name:
Physician's Address:
Date of Last Doctor's Visit:
Reason for Last Doctor's Visit:

Emergency Contact:
Emergency Contact Phone Number:

Risk Factors:
Smoker	Past Present
Hypertension	Past Present
Elevated Cholesterol	Past Present
Diabetes	Past Present
Type-A Behavior	Past Present
Stress	Past Present
Overweight	Past Present
Underweight	Past Present
Inactivity	Past Present

Current Health:
Medications	Yes No If yes, what type?:
Heart History:	Yes No If yes, what type?:
Surgery:	Yes No If yes, what type?:
Arthritis:	Yes No If yes, what type?:

Previous Injuries:
Neck Problems:	Yes No If yes, provide details:
Shoulder Problems:	Yes No If yes, provide details:
Elbow Problems:	Yes No If yes, provide details:
Wrist Problems:	Yes No If yes, provide details:
Back Problems:	Yes No If yes, provide details:
Hip Problems:	Yes No If yes, provide details:
Knee Problems:	Yes No If yes, provide details:

Spinal Trauma Tendonitis Bursitis Broken Bones Joint Injuries

Details of above:

By checking this box before submitting the form, I, intending to be legally bound, and recognizing the danger involved in physical exercise, do agree as follows:
In consideration for the services rendered by TODAY! Fitness, LLC. in the establishment of a personal physical-fitness program for my benefit, I agree to waive any rights, claims, or damages for injuries which may occur as a result of my participation in said fitness/nutrition program.
I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program.
I understand that TODAY! Fitness, LLC. is a personal training company and not a medical doctor, and that they will in fact be relying on my representations and disclosures regarding my health and physical condition.
I also do not hold the aforementioned institutions liable for any personal injuries, bodily injuries, or property damage while going to and from the aforementioned property.


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