Serving Summerlin & West Las Vegas, Nevada
Fitness Evaluation:
Evaluation Form
Name
*
Email
*
Phone
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Gender
Male
Female
Age Range
18-25
26-35
36-45
46-55
56-65
Over 65
Height/weight
Current body condition
Under-weight
Average
Slightly Overweight
Overweight
Greatly Overweight
Do you have high blood pressure, asthma or other chronic breathing problem, back problems, arthritis or other condition that could interfere with your ability to exercise?
Yes
No
Do you smoke?
Yes
No
Are you currently taking any medication that could interfere with your ability to exercise strenuously?
Yes
No
Current Exercise Habits
Approximately how many minutes per week do you currently spend in some type of strenuous exercise?
Less than 1 hour per week
60-90 minutes per week
90 minutes - 2 hours per week
2-3 hours per week
More than 3 hours per week
How often to you engage in exercise that raises your heart rate and causes you to sweat for at least 10 minutes?
Almost never
1-2 times per week
3-4 times per week
More than 4 times per week
How often do you engage in exercise that helps you increase in muscle flexibility.
Almost never
1-2 times per week
3-4 times per week
More than 4 times per week
How often do you engage in exercise that helps you build muscle?.
Almost never
1-2 times per week
3-4 times per week
More than 4 times per week
Your Goals
If you had to choose one physical fitness goal to attain in the next 4 months, what would it be.
Lose 10 pounds
Improve cardiovascular health
Lose inches
Feel more healthy
Establish fitness plan and regimen
Have you ever used a Personal Fitness trainer before?
Yes
No
What has typically been the hardest part about staying in shape?
Finding time
Don't like to exercise
Remaining disciplined
Physical pain,injury or sickness
Other
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