Program Evaluation

Before providing a personalised program to assist you with achieving your desired results, we require you to complete this Program Evaluation.  This is necessary to ensure we acquire a complete understanding of what you are after from your program as well as become educated in a fitness, sporting and medical history..

Contact Details

Date 
Name  *
Address 
Phone 
Email  *
Recommended By 

Fitness & Lifestyle Goals

Date of Birth 
Age 
Current Weight 
Goal Weight 
Height 
Current Body Fat %? 

How Can I Help You?

Improve Strength 
Improve Flexibility 
Improve Muscle Tone & Shape 
Improve Cardiovascular Fitness 
Weight Loss 
Gain Weight/Muscle 
Increase Energy 
Performance Nutrition 
Sports Specific Training 
Sport (if applicable) 
Additional Goals 

Your Current Fitness & Training Program

Are you currently involved in a regular exercise program?  yes   no  
Novice Athlete 
Immediate Athlete 
Elite Athlete 
Please explain, Include Activity, Duration, Frequency 

Medical History

Do you smoke?  * yes   no  
Have you ever smoked?  * yes   no  
If you currently smoke how often? 
Do you use alcohol?  * yes   no  
If yes how much? 
And how often? 
Do you drink coffee or beverages that contain caffeine?  *
Have you ever been on a diet?  * yes   no  
If yes please provide details 
Are you currently using sports supplements?  * yes   no  
If yes please list 
What are your favourite foods?  *
Do you have any medical conditions?  * yes   no  
Please list and include medication you are currently taking 
Do you currently or in the past had any injuries?  * yes   no  
Please give details 
Do you have any other comments or information you would like to add? 
I do hereby state that I have to the best of my knowledge and belief given a correct and accurate medical and history report.  *