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Forms

The following forms are to be completed by everyone who will be undertaking an online personal training programme with Personal Evolution.

Additional forms and records will be sent in Microsoft word format.

Please complete BOTH forms before commencing your programme.

Health Screen

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

City*
City*

Country*
Country*

Home Phone

Business Phone

Date of birth*
Date of birth*

Date*
Date*

List any medications you take regularly*
List any medications you take regularly*

Do you have diabetes?*
Do you have diabetes?*

	YES
	NO

Have you ever had a stroke?*
Have you ever had a stroke?*

	YES
	NO

Do you or have you ever suffered any form of heart disease?*
Do you or have you ever suffered any form of heart disease?*

	YES
	NO

Do you have asthma that requires medication?*
Do you have asthma that requires medication?*

	YES
	NO

Are you pregnant?*
Are you pregnant?*

	YES
	NO

Is there any other health reason that may affect your participation in an exercise program?*
Is there any other health reason that may affect your participation in an exercise program?*

	YES
	NO

If yes provide details...

Do you ever experience pains in the chest?*
Do you ever experience pains in the chest?*

	YES
	NO

Do you ever feel dizzy during physical exertion?*
Do you ever feel dizzy during physical exertion?*

	YES
	NO

Do you ever experience unusual fatigue or shortness of breath?*
Do you ever experience unusual fatigue or shortness of breath?*

	YES
	NO

Do you ever get the feeling that your heart is beating faster or skipping beats?*
Do you ever get the feeling that your heart is beating faster or skipping beats?*

	YES
	NO

Do you smoke cigarettes regularly?*
Do you smoke cigarettes regularly?*

	YES
	NO

Do you have high blood pressure?*
Do you have high blood pressure?*

	YES
	NO

Have any of your close relatives suffered a heart attack or stroke before the age of 65?*
Have any of your close relatives suffered a heart attack or stroke before the age of 65?*

	YES
	NO

I certify that all the above information is true and correct to the best of my knowledge. Please type your name in the box below as a digital signature.*
I certify that all the above information is true and correct to the best of my knowledge. Please type your name in the box below as a digital signature.*

Please enter the word that you see below.

Goals and Needs Analysis

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

City*
City*

Country*
Country*

Your primary goal in one sentence (BE SPECIFIC).*
Your primary goal in one sentence (BE SPECIFIC).*

What has kept you from achieving that goal in the past?*
What has kept you from achieving that goal in the past?*

When in the past have you been most satisfied with your physical condition? Provide details.*
When in the past have you been most satisfied with your physical condition? Provide details.*

When in the past have you been most dissatisfied with your physical condition? Provide details.*
When in the past have you been most dissatisfied with your physical condition? Provide details.*

What potential obstacles are there that could stop you from achieving your fitness goals?*
What potential obstacles are there that could stop you from achieving your fitness goals?*

Are you prepared to take appropriate action to ensure you break through them?*
Are you prepared to take appropriate action to ensure you break through them?*

Why is this time any different from previous failed or sub-par attempts?*
Why is this time any different from previous failed or sub-par attempts?*

Three things you dislike in an exercise programme*
Three things you dislike in an exercise programme*

Three things you like in an exercise programme*
Three things you like in an exercise programme*

Is there anything else that may affect you achieving your goals, either positive or negative?*
Is there anything else that may affect you achieving your goals, either positive or negative?*

Specify your exact goal/s in tangible, measurable numbers such as amount of weight to lose, marathon goal, power-lifting increases etc.*
Specify your exact goal/s in tangible, measurable numbers such as amount of weight to lose, marathon goal, power-lifting increases etc.*

What equipment/gym facilities do you have available?*
What equipment/gym facilities do you have available?*

List specific equipment you will be using in your training program. For gym access just type "Gym".*
List specific equipment you will be using in your training program. For gym access just type "Gym".*

Where will you primarily be working out?*
Where will you primarily be working out?*

How much time can you or are you willing to dedicate to training each training day?*
How much time can you or are you willing to dedicate to training each training day?*

How often are you able to workout per week?*
How often are you able to workout per week?*

Are you ready to get stuck in and achieve your fitness goals?*
Are you ready to get stuck in and achieve your fitness goals?*

	YES
	NO

Please enter the word that you see below.

SBI!