For a more detailed evaluation and feedback, please complete as much of the below information as possible. All information collected is for use by AB&F for the sole purpose of providing you with the best possible services. No information is shared with any third party groups or organizations! The more you provide, the more we can service your wants and needs.

* Must provide these details to ensure a response.

 

Your Contact Details

Name:

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Email Address:

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Street Address:

City:

State:

Postcode / Zip:

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Contact Phone Number:

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Business Phone Number:

Fax Number:

Your Personal Information

Date of Birth:

Age:

Sex:

Female Male

Height:

Your present weight:

Weight (12 months ago):

Weight (at 21 yrs of age):

Your Physical Condition

Do you have any physical or medical conditions that would limit you from engaging in a safe exercise program?:

No Yes

If yes, please indicate why ...
(include any surgery you may have had):

Your Lifestyle

Your current occupation:

How many hours do you work per week?:

How do you spend most of your time at work?:

Do you smoke?:

No Yes

If yes, how many per day?:

Indicate your daily stress level on a scale of 1-10
(10 being very stressed):

Indicate your energy level on a scale of 1-10
(1 being low energy):

Your Physical Activity

What is your favorite physical activity?:

How often do you do this?:

How many times per week do you engage in moderate or strenuous exercise for at least 20 minutes?:

If yes, describe what you do:

How long have you been doing this?:

Have you ever begun an exercise program and then stopped?:

No Yes

If yes, why did you stop?:

Your Workout Availability

How many times per week are you able to train?:

Please indicate your preferred times and days you wish to train:

Please provide a day and time that is convenient for you to schedule your initial Fitness consultation:

Please provide an alternative day and time:

What would you like to achieve in a fitness program? (anything specific?):

In order to design a training program that would best suit your needs, please indicate what you are looking for in a personal trainer (ie: gender, highly motivating, passive or any other physical or mental characteristic):

Check any of the services/activities that interest you:

Strength and Fitness Training
Weight Management
Body Building
Sport Enhancement Conditioning
Nutritional Counseling
Boxing and/or Thai Kickboxing

Where did you heard about
American Boxing & Fitness:

Questions/Comments: