Client Information Form
Thank you for signing up for my 16 week personalized fitness program. By signing up you agree to our Terms and Conditions. Please consult your doctor before starting a new wellness program. Fill out all the information below so we can get to know you better. Your information will never be shared and is completely confidential. The more information you provide the better :)
General
Name *
Your answer
Best number to reach you at? *
Your answer
E-mail Address *
Your answer
Sex
Age *
Your answer
Height *
Your answer
Weight *
Your answer
Body Fat % (If you know it)
Your answer
Measurements - Bust/Chest *
inches
Your answer
Measurements - Waist *
inches
Your answer
Measurements - Hips *
inches
Your answer
Measurements - Right Bicep *
inches
Your answer
Measurements - Left Bicep *
inches
Your answer
Measurements - Right Calf *
inches
Your answer
Measurements - Left Calf *
inches
Your answer
Marital Status
Do you have children?
Birthdate
Your answer
Occupation *
Your answer
Does your occupation require extended periods of sitting?
Your answer
Does your occupation require you to wear heels (dress shoe)?
Your answer
How did you hear about this program? *
Your answer
What are your reasons for joining the program? *
Your answer
What do you hope to get out of completing the program? *
Your answer
Do you workout at a gym or at home? *
If at home what equipment do you have available?
Your answer
What is your experience with weight training, dumbbells, barbells, machines, etc? *
Your answer
Do you workout in the morning or in the evening? What time usually? *
Your answer
How many days a week can you commit to weight training? *
Your answer
What do you love most about your life right now?
Your answer
if you could, what is something you would change about your life right now?
Your answer
Have you read and agreed to the Terms and Conditions? *
You must read and agree to the T & C before starting the program found here: http://theblissfulchef.com/terms-and-conditions/
Required
Medical History
Are there any health conditions that I should know about? *
Your answer
Has your doctor ever diagnosed you with a chronic disease such as any of the ones listed below?
If you checked any box above, has your doctor given you written clearance to start an exercise program?
If not, please get clearance from your doctor before starting our program.
Your answer
Suffered any serious injuries or have had surgeries? *
Your answer
Do you have pain in any of these areas.
If yes to previous question please explain.
Your answer
Are you taking any medications? *
If yes, please list them
Your answer
Do you have any allergies to anything?
Your answer
What is your digestion like?
Your answer
Lifestyle & Diet
How many hours of sleep do you get each night? *
Your answer
What is your energy level like throughout the day? *
Your answer
How many times a week do you exercise? *
Your answer
What kind of activities/ exercises do you take part in?
Your answer
What is your work activity like?
Your answer
What is your diet like?
Your answer
Do you drink coffee or other stimulants?
Your answer
What are your favorite foods? *
Your answer
What are your least favorite foods? *
Your answer
Do you or did you drink, smoke or use drugs?
Your answer
What are your hobbies?
Your answer
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