Fitness Assessment Form - Wellness Corporation

Name: *

First

Last

Surname:

Sex:

Male
Female

Birthday://

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home:

Work:

Mobile:

Medical History

Doctor:

Date of last checkup://

Has anyone in your family under 60 suffered heart disease, stroke, raised cholesterol or sudden death?

Yes
No

Are you pregnant?

Yes
No

Have you given birth within the last 6 weeks?

Yes
No

Do you have any infectious diseases?

Yes
No

Have you been hospitalised recently?

Yes
No

Are you taking any medication at present?

Yes
No

If so, give details:

Have you ever had or do you have any of the following:

If you circled any of the above please give details:

Do you smoke?

Yes
No

If YES, how many a day?

Are you dieting or fasting?

Yes
No

Please give details:

Do you suffer from Stress and/or Insomnia?

Yes
No

Have you been doing any exercise recently?

Yes
No

Type of activity:

Intensity level:

Easy
Moderate
Hard

What do you hope to achieve from circuit classes and/or personal training sessions/programs? (Please circle)

I understand this information is to be used as a guide to provide me with a suitable exercise program based on my current medical condition. I understand that if medical clearance is required, I will consult my physician and obtain a clearance.

I agree to advise the trainer immediately there is any change in my medical condition or if I experience any discomfort while training.

I agree and accept that the Wellness Corporation or its officers or employees will not be liable for any personal injury or damage to my property while I am participating in any activity in the Wellness Corporation or any injury or damage resulting in any undisclosed medical conditions or issues.

Signature:

Date://

	Start	Goal	Eval 1	Eval 2	Eval 3
Date
Height
Weight
Resting Heart Rate
Training Heart Rate
Skin fold measurement
Bicep
Skin fold measurement tricep
Skin fold measurement subscapular
Skin fold measurement supralliac
% body fat
% lean mass
Neck
Chest
Biceps (right/left)
Forearms
Waist
Hip
Upper thigh (right/left)
Calf

OFFICE USE ONLY

Medical clearance required

Yes
No

Comments:

Medical History

OFFICE USE ONLY

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