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Please fill out the following goal and fitness assessment form to receive free consultation.

*Applicant’s Name:

Date of Birth:

Co-Applicant’s name:

Date of Birth:

Address:

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zip:

Work Phone:

Home Phone:

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Have you joined a health club before?

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Which One?

How often do you currently exercise?

How serious are you about getting in shape?

Do you have any medical or physical restrictions that would prevent you from exercising?

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If yes please explain

Your primary fitness goals:

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Weight loss

Conditioning

Nutritional counseling

Fitness

Why is this goal important to you?

By when do you want to accomplish these goals?

How long have you thought about getting started?

What motivated you to come in today?

Present Work Out Load:

Health Status:

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