Date of Assessment

Full Name

Membership ID

(If Applicable)

How often do you exercise?

• Daily

• 3-5 times a week

• 1-2 times a week

• Rarely

What are your primary fitness goals?

(Check all that apply)

• Weight Loss

• Muscle Gain

• Flexibility Improvement

• Increased Endurance

What types of exercise do you currently engage in?

(Check all that apply)

• Cardio

• Strength Training

• Group Classes

• Yoga/Pilates

Do you have any pre-existing medical conditions?

If yes, please specify:

Are you currently taking any medications?

If yes, please specify:

Additional Comments/Concerns