New Client Signup Form – Pursuit Training

Welcome to the Pursuit Training Client Sign up form. Thank you for your interest in joining us. The following form will take approximately 15 minutes to complete. Please be as honest as possible when considering your training goals. If you have any questions or concerns, feel free to contact us. We look forward to sharing your fitness journey.

Registration – Client Form

Today’s Date:

First Name:

Last Name:

Date of Birth:

Mailing Address:

Email Address:

Phone Number (h):

Phone Number (c):

Date of last medical:

Dr’s Name:

Dr’s phone number:

Results of last medical:

Is there a history of family heart disease or high blood pressure?

Are you currently taking any medications?

If so what medications and conditions?

Have you ever been diagnosed with a chronic disease such as (select all that apply):

Asthma Diabetes Immune Deficiency Other

If you selected “other” please provide details

Do you have any injuries that Pursuit Training should be aware of (select all that apply):

Neck Shoulders R/L Elbows R/L Wrists R/L Hips R/L Knees R/L Ankles R/L Low Back Upper Back

1. Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?

2. Do you feel pain in your chest when doing physical activity?

3. In the past month, have you had chest pain when not doing physical activity?

4. Do you ever lose your balance because of dizziness or ever lose consciousness?

5. Do you have a bone or joint problem that could be made worse by a change in physical activity?

6. Do you know any other reason why you should not do any physical activity?

7. For women only – Are you pregnant?

8. Are you over 69 years of age?

9. Do you drink alcohol on a weekly basis?

If so, how much per week?

10. Do you smoke?

If so, how many per day?

Is there any other medical or non-medical condition that Pursuit Training should be aware of?

If so, please explain as best possible

I want to stretch your limits to help you realize and overcome your self-set impossibilities. All great achievements begin with a pre-set impossible goal, what “impossibility” will you achieve? Looking one year ahead from this moment what would you have to see, feel or be able to do to have a sense of accomplishment?

Please list 5 goals. Beside each goal I ask that you write why you want to achieve this goal. When we know the “why” the how will come.

Of the above listed goals, to date what has prevented you from achieving each goal?

To help set a numeric value to where you currently stand, rate from 1 – 10 (1 low, 10 high) your feelings to the following statements:

I hate my appearance – I love my appearance

I have no energy – I have an abundance of energy

I have strength limitations – I have never been stronger

I have very low endurance – I have very high endurance

I have flexibility limitations – I have never been more flexible

I have a horrible eating habits – I have excellent eating habits

I hate to work out – I love to workout

I have great difficulty sleeping – I wake up rejuvenated daily

Stress controls my life – I feel great and have low stress levels

My goals are impossible – It is a matter of time before I achieve my goals

How many times per week do you plan on training with a Pursuit Training trainer?

What day(s) and time(s) of the week fit your schedule best to train with your Pursuit Training trainer?

How many times per week do you plan on exercising on your own?

Do you currently follow any fitness routine?

If so, please describe.