Health & Fitness Assessment

This is Your Health & Fitness Profile. It will give us a clear account of your goals and health background in order to create the best workout plan tailored specifically for you. Once we have your starting point we will map out a clear route to help you achieve your goals. Please take a few minutes to accurately fill in the following information and submit. Thank you!

First Name

Last Name

Phone *

Email *

Date of birth *

Height *

Address *

Street Address

City

State

Country

Postal code

Do you need an in-home, at your gym, outdoor or virtual personal trainer? *

What days do you want to train? *

What times do you want to train? *

What is your goal? Choose Top 3. *

Do you have any other goals? Please type them here. *

You must truly care about your goal if you are going to put in the work required to get it, so WHY do you want this goal? *

What is the biggest obstacle/s that are preventing you from reaching this goal? And what frustrations do you feel on a daily or weekly basis as the result? *

How much time (at the gym and/or home) can you devote to achieving your goal? *

1-2 hours per week

3-4 hours per week

+5 hours per week

How do you think a personal trainer can best assist you in accomplishing your goals? *

What coaching style would you respond to best? *

High Energy Drill Sargent

Even Keeled with Tough Love

Laid Back with Positive Enforcement

Do you currently have pain or injuries (for example, back, hip, knee) that could be made worse by physical activity? If Yes, please explain: *

Do you smoke or vape? *

Yes

No

Do you have any heart or breathing conditions that would prevent or limit exercise? If Yes, please explain: *

Have you ever had surgery in the past? If Yes, please explain: *

Do you take any medications or supplements? If Yes, please note: *

What is your preferred eating style? *

Anything ( no major preferences or restrictions )

Mediterranean ( plant foods, healthy fats & moderate amounts of lean protein )

Paleo ( emphasizes meats, vegetables, & healthy fats )

Vegetarian ( plant based w/ small amounts of eggs & dairy )

Ketogenic ( high fat, very low carbohydrate diet )

Vegan/Fully Plant Based ( all plants, no animal products of any kind )

What recreational and stress relieving activities do you do to recover? (ex. reading, walking, sports, art & crafts, music, etc) *

How would you describe your current job or daily routine? *

Sedentary (Spend most of the day sitting, e.g. bank taller, desk job)

Lightly Activity (Spend a good part of the day on your feet, e.g. teacher, salesman)

Active (Spend a good part of the day working on your feet, e.g. waitress, mailman)

Very Active (Spend most of the day doing heavy physical activity, e.g. bike messenger, carpenter)

What days and times do you have available for personal training sessions? *

Is there is there is anything else you would like us to know in order to better help you? If Yes, please feel free to add here: *

It is recommended that you undergo a medical evaluation prior to participating in physical activities. Do you understand that Hydrogen Fitness is not a medical service, and therefore you exercising at your own risk? *

Yes

Please Sign Here: *

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