Training Services Application

New Client Application

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Country*

Phone Number (required for online training FREE consult)

In Person Consult Only-Preferred times to meet

	Mornings
	Afternoons
	Evenings

Date of birth (mm-dd-yyyy)*

Gender*

	Female
	Male
	Other

Height*

Weight*

Do you smoke (if you checked 'Yes' or 'sometimes') indicate below how frequently*

	Yes
	No
	Sometimes

Smoking frequency?

Are you diabetic?*

	Yes
	No

If you ARE diabetic, Type I or II?

	Type I
	Type II

1. Has your doctor diagnosed you with a heart condition and recommended ONLY medically supervised physical activity?*

	Yes
	No

2. Do you frequently have chest pains performing physical activity?*

	Yes
	No

3. Have you had chest pain when NOT doing physical activity*

	Yes
	No

4. Do you lose your balance due to dizziness or do you ever lose consciousness? *

	Yes
	No

5. Do you have a bone, joint or other health problem that causes you pain or presents limitations that must be addressed when developing an exercise program (i.e. osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, epilepsy, respiratory ailments, back problems, etc.)?*

	Yes
	No

6. Are you pregnant now or have you given birth within the last 6 months?*

	Yes
	No

7. Have you had a recent surgery (within the last 6 months)?*

	Yes
	No

If you marked YES to any of the previous 7 questions, please elaborate here:

Do you take any medications, either prescription or non-prescription, on a regular basis?*

	Yes
	No

If 'YES' to the above question, what is the medication for?

How does the medication affect your ability to exercise or achieve your fitness goals?

When were you in the best shape of your life?*

Are you currently physically active?*

	Yes
	No

How long have you been unhappy with your current health or weight situation?*

	Less than 1 year
	Between 1 and 3 years
	More than 3 years

What, if anything, stopped you in the past with your training?

What are 1-3 short term goals for the next 3 months?*

What are 1-3 long term goals for the next 12 months?*

How will you feel once you've achieved these goals? Be specific.

How committed are you to making a positive physical and mental change in your life?*

	1. I'll just watch other people workout on social media.
	2. I'm only in it to get ready for an event.
	3. I'm ready to go, I just need someone to guide me.
	4. I've got good fitness and/or nutrition habits and I'm ready for the next level!
	5. I'm so dialed in, people ask me for fitness advice!

Please indicate where you prefer to exercise*

	Inside
	Outside
	Combination

Please indicate how you like to exercise*

	Alone
	With another person
	Combination

Please indicate when you like to exercise*

	Morning
	Afternoon
	Evening
	Variable times

What is your favorite movie or book?

When are you ready to start?*

	Today! Let's do it!
	Next week or next month
	I'm not ready to change yet

PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT: I wish to participate in the exercise and online training program offered by Myhomefitnessplan. I understand there are inherent risks in participating in a program of moderate or strenuous exercise. I agree that Myhomefitnessplan shall not be liable or responsible for any injuries to me resulting from my participation in the online fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Myhomefitnessplan, its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program. This Release shall be binding upon my heirs, executors, administrators and assigns. *

	Yes
	No

Client Signature (please enter full name in box to the right)*

Date (dd-mm-yyyy)*

GDPR*

	I am at least 16 years of age.
	I have read and accept the privacy policy.
	I understand that you will use my information to contact me or send me the information I requested.

Please enter the word that you see below.