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Boxing and Fitness Client Evaluation Form
Please fill out the form below
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Step 4
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Full Name:
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First Name
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Last Name
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Birth Date:
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The value must be less than or equal to 2147483647
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Address:
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City
State
Country
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
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Bangladesh
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Belize
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Canada
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Chad
Chile
China
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Comoros
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Croatia
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Dominican Republic
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Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
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Hungary
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India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
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Korea North
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
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United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Zambia
Zimbabwe
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Zip Code
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Mobile No:
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Invalid phone number.
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Email id:
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Please enter valid email address
Medical History
Have you had any family history of chronic disease (heart disease, diabetes, etc):
Yes
No
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Have you ever been diagnosed or treated for any chronic disease including asthma:
Yes
No
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Are you currently taking any medication:
Yes
No
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Any other conditions that we need to be aware of (i.e. Past or present injuries, etc):
Yes
No
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Personal Details
If you have answered YES to any of the above questions, you must obtain a medical clearance prior to carrying out a physical exercise program.
Health Related Behaviours
Do you smoke:
Yes
No
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If yes, how many a day:
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If yes, how much per week:
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How many times on average do you eat fast food per week:
1-2
3-4
5-7
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How many hours of sleep do you normally get per night:
0-3 hrs
4-6 hrs
7-8 hrs
8-10 hrs
10 hrs+
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Psychological
Please rate the following. One star being negative to five stars being positive
I have a positive attitude towards thing:
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My job stresses me out.:
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I am in the best shape of my life.:
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I would rate my current health.:
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I am serious about acheiving my goals:
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Goals
Do you have any health related goals (i.e. Lower blood pressure, etc):
Yes
No
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Do you have specific goals related to body composition (i.e. weight loss, build biceps etc):
Yes
No
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Do you have any performance specific goals (i.e. Increase 10 km run, increase chest strength, etc):
Yes
No
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Do you wish to achieve any of these goals in a specific time frame:
Yes
No
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Liability Waiver
Please read carefully before submitting form.
I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Fearless Boxing & Fitness.
Having such knowledge, I hereby release Fearless Boxing & Fitness, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity.
I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.
Please tick box in agreement to the above liability waive
I Agree
I Agree
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