Personal Fitness Lifestyle Assessment
*Please note that all fields are required
How would you like to be contacted? Home E-Mail
What is the best time to reach you? Day Evening
Are you presently involved with any fitness activities? Check all that apply Aerobic Classes Cardio (Machine Based) Weights/Resistance Training Cycling/Spinning Running/Jogging Walking Sports Martial Arts Pilates Yoga Other None
How many times a week are you active? 1 2 3 4 5 more
When do you prefer to excercise? Morning Afternoon Evening
How would you rate your fitness level? Beginner Novice Intermediate Advanced
On a scale of 1 = Poor to 10 = Excellent, how would you rate your:
What are your top three reasons for excercise? Weight Loss Cardiovascular Endurance Muscle Gain Increase Strength Body Fat Reduction Toning Flexibility Stress Reduction Increase Energy Athletic Performance Medical Social Time Weight Loss Cardiovascular Endurance Muscle Gain Increase Strength Body Fat Reduction Toning Flexibility Stress Reduction Increase Energy Athletic Performance Medical Social Time Weight Loss Cardiovascular Endurance Muscle Gain Increase Strength Body Fat Reduction Toning Flexibility Stress Reduction Increase Energy Athletic Performance Medical Social Time
What is your height? 5 6 0 1 2 3 4 5 6 7 8 9 10 11
What is your weight? lbs
Do you have any specific health concerns check all that apply High Blood Pressure High Cholesterol Diabetes Heart Disease Dizziness Fainting Joint Pain Other
Please list any other known medical conditions that you have or have been treated for in the last 5 years:
Please list any current or past injuries:
Has a doctor or other professional recommended that you NOT excercise? Yes No
Do you smoke? Yes No
How active is your occupation? Sedentary Light Moderate Heavy
What are you most interested in? Check all that apply Personal Training Weights/Resistance Training Cardio Group Fitness Classes How did you hear about Fitness Clubs of Canada? Check all that apply Mobile Sign Flyer Newspaper Building Signage Website Friend
DISCLAIMER The information on this site is intended for general reference purposes only and not to address specific medical conditions. Prior to participating in any exercise program or activity, you should seek the advice of your physician.
You must be 18 years of age or older or have parental consent to provide any personally identifying information through our website.
By submitting this form, I acknowledge that I have read and agree to the PRIVACY POLICY I also acknowledge that I will be contacted by Fitness Clubs of Canada regarding this inquiry.
