Robi Quezada Certified Fitness Trainer (CFT) ISSA

Fitness Assessment Information Sheet

Participant Name

Date of Birth

Address

City, state, zip _____

Phone (h) _________(c) Email

Fitness Goals
(Please be as specific as you can in telling us about your fitness goals. Examples would be; lose 3 inches
around my waist, improve cardiovascular endurance, develop muscle tone in my arms etc.)
1. What is your goal and how do you plan to get there?_________________________________
_____________________________________________________________________________
2. What is a realistic time frame? __________________________________________________
3. What obstacles, if any, may prevent you from achieving your goals? ____________________
_____________________________________________________________________________
4. How many times a day do you eat? ___ Describe Meals? ___Poor___Good
Water intake ___Poor___Good
5. How can I help as a trainer? ___________________________________________________
6. How many days/wk can you consistently exercise? __1__2__3__4__5__6__7
7. Best days and times to exercise? ________________________________________________

Exercise History
Circle the number which best represents your exercise history:
0 = never been one to exercise regularly
1= have sporadically worked out in the past but not now
2 = somewhat regular in working out but not feeling like I’m seeing any results

Do you have prior experience with strength training? If yes, please explain.
If you have done cardiovascular exercise in the past, what types of activities have you done and how hard (on

a scale of one to ten, with 1 being light exercise) would you say you worked?

Time Committed To Exercise

How much time do you see yourself being able to commit to a single exercise session? _______
How many days a week can you commit to following an exercise program? ___ ____

Medical/Health Questionnaire
Please answer every question as accurately as possible by circling yes or no. Your information will remain
confidential. We ask that you sign and date this page. Individuals may be required to get physician clearance
based on the information supplied on this form.

• Do you have any personal history of heart disease? Yes NO

• Any history of metabolic disease (thyroid, renal, liver)? Yes NO
• Do you have diabetes? Yes NO
• Have you experienced pain or discomfort in your chest? Yes NO
• Have you had any problems with dizziness or fainting? Yes NO
• Do you have difficulty breathing? Yes NO
• Have you experienced rapid throbbing or fluttering of the heart? Yes NO
• Have you experienced severe pain in leg muscles during walking? Yes NO
• Do you have a heart murmur? Yes NO
• Do you have any family history of cardiac or pulmonary disease? Yes NO
• Have you been assessed as hypertensive on at least two occasions? Yes NO
• Has your serum cholesterol been measured at greater than 240mg/dl? Yes NO
• Has your HDL (good cholesterol) been measured at greater than 60 mg/dl? Yes NO
• Are you a smoker? Yes NO
• Would you characterize your lifestyle as sedentary? Yes NO
• Are you currently being treated for high blood pressure? Yes NO
• Are you currently pregnant or nursing? Yes NO
• Are you over 65 and not accustomed to vigorous exercise? Yes NO
• Have you had surgery in the last 6 months? Yes NO
• Has your physician advised you to exercise? Yes NO
• If yes, will he/she require clearance prior to starting an exercise program? Yes NO
• Do you have any history of bone, joint, muscle or ligament injuries? Yes NO
Medications
Please select any medications you are currently using:
Diuretics Diabetes/Insulin
Beta Blockers Anti-inflammatory
Vasodilators Calcium Channel Blockers
Alpha Blockers Other Cardiovascular
Cholesterol

Other drugs (please list)

Waiver and Release of Liability

In consideration of Trainer’s agreement to instruct, assist, and train me, I hereby agree to hold harmless Trainer, its
respective representatives, executors, agents, and assigns from any and all claims, demands, damages, rights of
action or causes of action, present or future, arising out of or connected to my participation in any and all Activities,
use of Equipment, or any and all acts or omissions, including negligence by Trainer and his Representatives. This
waiver and release of liability includes, but is not limited to, (a) Injuries and Changes to myself and/or others,
including but not limited to Trainer, that may occur as a result of (i) Equipment that may malfunction or break; (ii)
any and all defects, latent or apparent, in the design or condition of Equipment; (iii) any and all slips, falls or dropping
of Equipment; (iv) any and all improper maintenance of Equipment or facilities; (v) any hazardous condition that may
exist on the premises, including, but not limited to, the specific workout area; and (vi) Trainers negligent instruction
or supervision; (b) damage to property, including but not limited to, Equipment and the premises.

Print name Signature Date