Evaluation Form

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When filling out this form you should be completely honest if I am to help you. Keep in mind that there are no vanities here. All of us are different in every way and need to be addressed as such. ALL of the information is strictly confidential and will not be shared with anyone or any kind of study whatsoever. The entire program will be sent back to you including your profile. I keep nothing except the satisfaction of helping you to a better lifestyle physically.

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Richard's One on One Fitness Evaluation Form.

Your Name: *

Address: *

City: *

State: *

Zip: *

Phone: *

Your Email: *

Age:

Height:

Weight:

Sex:

Fitness programs: (Weights you are currently using, aerobics, Pilates, machines, bands etc)

Measurements:
Neck

Chest:

Thighs:

Calf:

Waist:

Wrist:

Ankle:

Hips (at their widest point)

Body Type (Check One)

Slim

Medium

Heavy

Medications

What medications, for how long you’ve been on them, and what they are prescribed for

Vitamins

What vitamins are you currently taking and for how long have you been taking them?

Training

Length of time you have been training?

How many days a week?

Time off from any exercise type of formal training?

Level of condition as you see it?

Stress

List all stress factors you currently may be under. Including work, family, schools, children, financial, social etc.

Disabilities

Please list any disabilities of any type including surgeries, injuries, and diagnosed illnesses

Diet

List your main diet

List any and all junk foods

Additional Comments or Information you would like to tell Richard

Failure is Not an Option!

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