Program Questionnaire Client Information Name * First Name Last Name Email * Phone * (###) ### #### Sex Male Female Date of Birth * MM DD YYYY How many times per week are you going to workout? * Online training program workout days range from 1-4 days per week 1 2 3 4 What fitness equipment do you have available? (e.g. adjustable dumbbells ranging from 10-50 lbs, loop resistance bands, yoga mat, pull up bar) Fitness Goals What are your fitness goals? * Lose body fat Gain muscle mass Increase strength Improve cardiovascular endurance Prepare for a specific event Improve overall health Other Of the items selected above, provide as many details as possible about your MOST IMPORTANT fitness goal? * (e.g. how much do you want to lift? How many pounds do you want to lose? What time frame?) Exercise History What is your fitness experience level? * Absolute Beginner Novice Intermediate Advanced How many times do you workout per week on average? * 0 1-2 3-4 5+ Describe the type of workouts you do. Health History Check the box if you now have, or have you had in the past: * History of heart problems, chest pain, or stroke Elevated blood pressure Any chronic illness or condition Difficulty with physical exercise Advice from physician not to exercise Recent surgery (last 12 months) Pregnancy (now or within last 3 months) History of breathing or lung problems Muscle, joint, or back disorder, or any previous injury still affecting you Diabetes or metabolic syndrome Thyroid condition Cigarette smoking habit Obesity [body mass index (BMI) ≥30 kg/m2] Elevated blood cholesterol History of heart problems in immediate family Hernia, or any condition that may be aggravated by lifting weights or other physical activity Cancer Asthma None of the above Are you taking any medications, supplements, or drugs? If so, please list medication, dose, and reason. * Does your physician know you are participating in this exercise program? * Yes No Do you have any current or past injuries that would impact exercise? * Yes No If yes, when and how did it happen? Is there anything else we should know about your medical history? Thank you! We will reach out to you shortly.