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The Day You're Told You're Fat
Training Services Application
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New Client Application
Please note that all fields followed by an asterisk must be filled in.
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Phone Number*
Date of birth (mm-dd-yyyy)*
Gender*
Female
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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
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I understand that you will use my information to contact me or send me the information I requested.
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2022