Client Information Form

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and interests, and is safe and effective.
Please complete and return to us at least 2 days prior to your first scheduled session.

Name *
Date Of Birth *
Date Of Birth
Address *
Phone *
Emergency Contact Phone *
Emergency Contact Phone
Fitness by Design will send information regarding your physical exercise program to your physician upon request.
Physician's Phone *
Physician's Phone
Physician's Address *
Physician's Address
Par-Q Form
Please mark YES or NO to the following.
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *
Do you frequently have pains in your chest when you perform physical activity? *
Have you had chest pain when you were not doing physical activity? *
Do you lose your balance due to dizziness or do you ever lose consciousness? *
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? *
Are you pregnant now or have given birth within the past 6 months? *
Have you had a recent surgery? *
Do you take any medications; wither prescription or non-prescription, on a regular basis? *
Fitness History
Have you been exercising consistently for the last 3 months? *
Exercise Related Questions:
Skip to next section if you are presently INACTIVE.
How often do you take part in physical exercise?
2) If your participation is lower than you would like it to be, what are the reasons?
List Frequency/Week, Average Length of Time and Rank Easy/Moderate/Hard
List Frequency/Week, Average Length of Time and Rank Easy/Moderate/Hard
List Frequency/Week, Average Length of Time and Rank Easy/Moderate/Hard
Goal Setting
How can a personal trainer help you? Please check all that apply. *
'SMART' Goals
In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure all your goals are “SMART”. S= Specific (Provide details, how long, how much etc.) M= Measurable (How will you measure whether you’ve reached your goals) A= Attainable (Be realistic, set smaller goals) R= Rewards-based (Attach a reward to each goal) T= Time Frame (Set specific dates for goals)
Where do you rate health in your life? *
How committed are you to achieving your fitness goals? *
Thank you, please submit!