Personal Information

First Name * Required

Last Name * Required

Date of Birth * Required

Age

Phone * Required

Email * Valid email required

Work Phone

ZIP Code

Occupation

Emergency Contact Name * Required

Emergency Contact Phone * Required

Physician's Name

Physician's Phone

02

Health Screening (PAR-Q)

Do you take any medications regularly? *

Yes No

03

Lifestyle

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Hours of sleep per night

Job type

Does your job require travel?

Yes No

Do you use a massage therapist regularly?

Yes No

Stress level (1 = very low, 10 = very high)

5

1 — Very Low10 — Very High

3 biggest sources of stress (optional)

Family & Background

Is anyone in your immediate family overweight?

Were you overweight as a child?

Yes No

04

Fitness History

When were you in the best shape of your life?

Have you been exercising consistently for the past 3 months?

Yes No

When did you first start thinking about getting in shape?

What stopped you in the past?

Current fitness level (1 = worst, 10 = best)

5

1 — Starting From Zero10 — Athletic

05

Nutrition

Nutrition quality (1 = very poor, 10 = excellent)

5

1 — Very Poor10 — Excellent

Meals per day (incl. snacks)

Glasses of water daily

Eat out (times/week)

Skip meals?

Yes No

Eat breakfast?

Yes No

Eat late at night?

Eat foods high in fat/sugar?

Know your daily calorie intake?

Yes No

Activities while eating?

Current vitamins or supplements

3 areas of nutrition you'd like to improve

Would you like nutritional education from your coach?

Yes No

06

Exercise History

How often do you exercise?

How long consistently active?

If lower than you'd like, why?

Lack of interest Illness/Injury Lack of time Other

Cardio

Times/week

Avg. duration (min)

Intensity

Want help with cardio conditioning?

Yes No

Strength Training

Times/week

Avg. duration (min)

Intensity

Exercises you currently do

Activities of Interest

07

Program Preferences

I prefer to exercise

Large groups Small groups Alone Combination

Preferred time of day

Morning Afternoon Evening

Realistic training days/week

Realistic session length (min)

How often to see a trainer?

Describe your ideal training week

08

Goal Setting

Priority Goal #1 * Please enter at least one goal

Priority Goal #2

Priority Goal #3

How important is achieving these goals?

Very important Somewhat important Not very important

How committed are you?

Very committed Semi-committed Not very committed

How long have you been thinking about these goals?

How will you feel once you've achieved these goals?

Where does health rank in your life?

High priority Medium priority Low priority

What's the most important thing your trainer can do for you?

Potential obstacles to your progress

3 methods you plan to use to overcome these obstacles

09

About You & Referrals

How did you hear about us?

Why did you choose Jax Liberty Fitness?

What would cause you to discontinue training?

Gift of Fitness — Refer a Friend

As a new client, you're invited to give two people a complimentary training session. List the names and contact info of two friends, family members, or coworkers who you think are ready to make a change.

Referral 1

Name

Phone

Referral 2

Name

Phone

10

Release & Agreement

Please read each item carefully and initial to confirm your understanding and agreement.

Full Legal Name * Required

Date * Required

Signature *

Draw your signature here

Guardian Signature (if under 18)

Client Information & Consultation Form

Personal Information

Health Screening (PAR-Q)

Lifestyle

Fitness History

Nutrition

Exercise History

Program Preferences

Goal Setting

About You & Referrals

Release & Agreement

Form Submitted

LINKS

CONTACT

Has your doctor ever said you have a heart condition and recommended only medically supervised physical activity?	Yes No
Do you frequently have pains in your chest when you perform physical activity?	Yes No
Have you had chest pain when you were not doing physical activity?	Yes No
Do you lose your balance due to dizziness, or do you ever lose consciousness?	Yes No
Do you have a bone, joint, or other health problem that causes pain or limitations (e.g. diabetes, osteoporosis, high blood pressure, arthritis, back problems, respiratory ailments)?	Yes No
Are you pregnant now or have given birth within the last 6 months?	Yes No
Have you had a recent surgery?	Yes No