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 *
Best number to reach you at? *
E-mail Address *
Sex
Clear selection
Age *
Height *
Weight *
Body Fat % (If you know it)
Measurements - Bust/Chest *
inches
Measurements - Waist *
inches
Measurements - Hips *
inches
Measurements - Right Bicep *
inches
Measurements - Left Bicep *
inches
Measurements - Right Calf *
inches
Measurements - Left Calf *
inches
Marital Status
Clear selection
Do you have children?
Clear selection
Birthdate
Occupation *
Does your occupation require extended periods of sitting?
Does your occupation require you to wear heels (dress shoe)?
How did you hear about this program? *
What are your reasons for joining the program? *
What do you hope to get out of completing the program? *
Do you workout at a gym or at home? *
If at home what equipment do you have available?
What is your experience with weight training, dumbbells, barbells, machines, etc? *
Do you workout in the morning or in the evening? What time usually? *
How many days a week can you commit to weight training? *
What do you love most about your life right now?
if you could, what is something you would change about your life right now?
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? *
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.
Suffered any serious injuries or have had surgeries? *
Do you have pain in any of these areas.
If yes to previous question please explain.
Are you taking any medications? *
If yes, please list them
Do you have any allergies to anything?
What is your digestion like?
Lifestyle & Diet
How many hours of sleep do you get each night? *
What is your energy level like throughout the day? *
How many times a week do you exercise? *
What kind of activities/ exercises do you take part in?
What is your work activity like?
What is your diet like?
Do you drink coffee or other stimulants?
What are your favorite foods? *
What are your least favorite foods? *
Do you or did you drink, smoke or use drugs?
What are your hobbies?
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