Date: __________________

First Name: _________________________ Last Name: __________________________

Address: ________________________________________________________________

City: __________________________________ State: _______ Zip: ________________

Home Phone: ___________________________ Email: ___________________________

Work Phone: ____________________________Cell Phone: _______________________

Emergency Contact Information: _____________________________________________

Gender: ________ Male _______ Female

Age: _____________ (yrs) Height: ______________ (in.) Weight: _____________ (lbs)



Wellness Questions



1. When were you in the best shape of you life? _________________________________

2. Have you been exercising consistently for the past 3 months? Yes No

3. When did you first start thinking about getting in shape? __________________________

________________________________________________________________________

4. What has prevented you from reaching your fitness goals in the past? ________________

________________________________________________________________________

5. On a scale 1-10, how would you rate your present fitness level (1=Worst 10=Best)? ____

________________________________________________________________________



Exercise Related Questions:



1. How often do you take part in physical exercise? (please circle)

5-7x/week

3-4x/week

1-2x/week

2. If your participation is lower than you would like it to be, what are the reasons?

Lack of Interest Illness/Injury Lack of time Other

3. How long have you been consistently physically active for? _______________________

4. What activities do you currently engage in? ____________________________________

________________________________________________________________________

What are you looking to accomplish? (Please choose all that apply)

o Increase strength	o Firm & Tone	o Increase energy
o Increase muscle	o Improve Flexibility	o Improve overall health
o Weight loss Goal? ________	o Weight gain Goal? ________

What best describes your eating habits? (please choose one)

o 1 meal per day	o 2 Meals per day
o 3 meals per day	o 4 or more meals per day

Do you take any vitamin or supplements? Yes No

If yes what? ____________________________________________________________________

What is the main area you are looking to improve? _____________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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E-mail: info@MasonryFitness.com