Jason Keigher :: Certified Personal Trainer located in New York City NY


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Please fill out this form to set up a FREE fitness consultation. (Free consultations are only available in Manhattan and are subject to availability.) This initial fitness assessment includes the following: Health History Questionnaire, Nutritional Analysis, Goal Setting, Body Fat % Measurement, Height and Weight Measurements, Resting Heart Rate Analysis, Blood Pressure Measurement.

REQUIRED INFORMATION
Full Name:
Email Address:
Phone Number:
OPTIONAL INFORMATION
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:

HEALTH AND FITNESS GOALS

What are your health and fitness goals? (be very specific)

Are you trying to diet and lose weight? yes no
If yes, how much do you want to lose? lbs.

What areas of fitness interest you? Strength training    Body Toning and Shaping
Weight Loss    Flexibility/Stretching    Yoga    Pilates    Body Building
Pre/Post Natal    Postural Correction    Nutrition    Other:

EXERCISE HISTORY

Do you currently exercise on a regular basis? yes no

If yes, describe the frequency, intensity, time and type of exercise routine:

MEDICAL HISTORY

List any injury or medical condition that may limit your ability to follow a fitness program:

TRAINING LOCATIONS, TIMES AND DATES
Select the days you would you like to workout? Sunday Monday Tuesday Wednesday Thursday Friday Saturday
What time of day would you like to workout? 6-9am 9am-12pm 12-3pm 3-6pm 6-9pm 9-11pm Other:
Where will you workout? Gym/Health Club Home Other: If you will workout at home, what type of equipment do you have?
MISCELLANEOUS
List any additional that may be important for me to know:
Thank you for filling out this questionnaire. I will notify you when I receive your information. If I need additional information I will call or e-mail.