Personal Plan - questionnaire Form

Synthesis Fitness

Personal Training
Welcome sheet - Client informations

This information is required in order for your personal plan to be designed specifically for you.
Full name*

First NameLast Name
Date Of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Phone Number*
E-mail*
Clients information - Health questionnaire

Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Please Tick*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this health questionnaire. All answers given are acurate to the best of my knowledge and understand giving false information may lead to injury to myself.
Initials*

Clear
What is your goal(s)? (Example: build muscle; lose body fat; get fitter.)*
What is your current weight and body fat? (If unsure about body fat, places like boots chemist and most gyms have machines. If this is inconvenient then leave this part out)*
How often do you exercise and what activities do you do? *
Do you have any food allergies and dislikes?*
Are you, or have you ever been a gym member.*
Have you ever used a personal trainer? If yes, then why did you stop?*
Describe your average daily routine.*
Write down the last full day of eating you can remember. (roughly will do)*
What type of programme are you interested in?*

online trainingonline nutritionOne to One personal traininggroup fitness classboxing trainingOther
Client information - Liability waiver
I am aware of the risks in observing or participating in the activities offered and sponsored by Synthesis Fitness and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property.
Initials*

Clear
The idea behind Synthesis Fitness is combining different elements to achieve overall success. No one thing is more important than the other. The use of muscular fitness, cardio fitness, core strength and education are used to enhance performance and drive you towards that end state.

That said, the important thing is enjoying the process. Work hard and communicate with your trainer.

The next stage will be the building of your programme and if requested a nutrition plan.

Please allow 72 hours for you plan to be designed and delivered to you.
Client informations - Signature
Signature*

Clear
Date*

MonthDayYear
My Products
prevnext( X )
One off diet plan£50.00

12 week training programme £100.00

12 week full diet and training programme £150.00

Please contact me to discuss£ Free

Total £0.00
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Synthesis Fitness

Welcome sheet - Client informations

Clients information - Health questionnaire

Client information - Liability waiver

Client informations - Signature