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Personal Fitness Analysis

Personal Fitness Analysis fill out and send in.

Get Fit by Melissa Personal Fitness Analysis

(Please answer all sheets-Thanks)

Name : _______________________________________________________________________________ Phone number: ________________________________________________________________________
E-Mail : ______________________________________________________________________________
Age : ________________________________________________________________________________
Gender : _____________________________________________________________________________
Height : ______________________________________________________________________________
Weight : ______________________________________________________________________________
Your Body Fat percentage % (if know) ______________________________________________________
Are you pregnant or plan to be in the near future : Yes No

Are you breastfeeding and your child is under 6 months of : Yes No

Are you breastfeeding and your child is 6 months of age or older? : Yes No

Have you (please select if you have or have ever had) : High blood pressure Heart disease Diabetes High Cholesterol level High tri-glyceride level Anemia Arthritis Asthma Osteoporosis Breast Cancer If Other (please explain)
Goals & Interest

Make a choice of your health & fitness Goals:

Lose weight
Gain weight
Improve nutritional status
Maintain weight
Become more fit
Increase strength
Look better

Receive regular updates on recent discoveries & trends in fitness industry :	Yes No.

Get great tips for fitting exercise in my schedule & making my progress as effective as possible in the time, I have available :	Yes No.
Nutritional Insight

Have you tried diet programs or are you currently on one?	Yes No.

Do you need help decreasing amount of fat and sugar in your diet :	Yes No.

Do you need help in increasing fiber, vitamins & minerals in your diet :	Yes No.

Do you currently take nutritional supplements :	Yes No.

If so name:

Are you currently on a restricted diet? (Check all that apply) :	Low fat / Low cholesterol Low protein Low sodium/low salt Diabetic diet Low fiber

How much water do you drink a day (8 OZ. Glasses) : _______________

Lifestyle Questions

The following describes my exercise routine :

Never
1-2 days/week
3-4 days/week
5 days or more

Is any cardiovascular exercise a part of your routine?

Yes No.

Have you ever done any kind of strength training until now?

Yes No.

If yes, then describe your strength training fitness level:

	Beginner's (less than one year total experience or none recently)
	Intermediate (1-3 years or none recently)
	Advanced (3+ years or more)

Do you include stretching in your workout program?

Yes No.

Your daily activity level :

Very inactive
Somewhat active
Moderately active
Very active

I am determined to achieve my goal weight :

Agree.
Slightly agree
Slightly disagree
Yes, please help me

I need support through :

Motivation
Tips on meal planning
Expert's advice
Emotional counseling.

GOALS

What Are Your Top 5 Goals:

Goal # 1: ______________________________________________________________

Goal # 2: ______________________________________________________________

Goal # 3: ______________________________________________________________

Goal # 4: ______________________________________________________________

Goal # 5: ______________________________________________________________

The Reasons For Your Goals Are:

Goal # 1 Reason: _______________________________________________________

Goal # 2 Reason: _______________________________________________________

Goal # 3 Reason: _______________________________________________________

Goal # 4 Reason: _______________________________________________________

Goal # 5 Reason: _______________________________________________________

Will talk about upcoming special's, classes and group envents. They do and can change so email or call for up to date info.