Basic Fitness Form

Tell us about your fitness goals and challenges. Your responses serve as the foundation of our complimentary, detailed, one-hour fitness evaluation as well as the fitness program we develop just for you.*
First Name
 
Last Name
 
Email Address
   
Phone
Date of Birth
RadDatePicker
RadDatePicker
Open the calendar popup.
Sex
How did you hear about Custom Fitness Consulting?
List allergies
Briefly describe your typical day
What are your fitness goals?

Activity

Which best describes your activity level?




If you work out, do you spend time on both aerobic training and resistance training?

Describe your workouts
Describe any injuries you have that would require exercise modifications.
What challenges keep you from being active?
List the equipment you have for working out (e.g., weights, treadmill, stability ball).

Diet

Which best describes your food choices?




How many meals a day do you eat (snacks not included)?
How many snacks a day do you eat?
How many times a week do you eat out?
What challenges keep you from eating healthful foods?
Do you cook?

List healthful foods that you like.
List healthful foods that you detest.
 

Waiver and Release of Liability

Participant is entering into a nutrition and or training program with the understanding that Participant has full responsibility for his/her health, physical, mental, emotional, and spiritual well being. Participant acknowledges that Custom Fitness Consulting has not and will not render any medical services or provide any medical diagnosis or advice regarding his/her physical or medical condition. Participant represents and warrants to Custom Fitness Consulting that he/she is in good health, has all necessary medical approval to participate in or use the Program and is otherwise competent and qualified to participate in or use the Program. Participant agrees that if at any time he/she believes it is unsafe for him/her to participate in any component of the Program or its activities or to follow its recommendations or advice, Participant will immediately discontinue his or her participation or use of the program.

Participant acknowledges and agrees that this Agreement is binding on Participant as well as his/her child/ward, heirs, executors, administrators, and assigns, and anyone else who may assert a claim on the Participant’s behalf. This Waiver and Release shall be deemed to be severable and, if any provision hereof shall be finally determined to be void, illegal or unenforceable, then it is the parties’ desire and intention that such provision be deeming automatically adjusted to the minimum extent necessary to conform to applicable requirements of validity, legality, and enforceability and, as so adjusted, be deemed a provision of this Waiver and Release as if it were originally included herein. PARTICIPANT HAS CAREFULLY READ AND UNDERSTANDS THE CONTENTS OF THIS BINDING WAIVER AND RELEASE WITH FULL KNOWLEDGE OF ITS LEGAL SIGNIFICANCE.


*Results May Vary: Fitness and/or weight loss results will vary from person to person. No individual result should be seen as typical. 
All information and tools presented within this site are intended for educational purposes. Any health, diet or exercise advice is not intended as medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before beginning a new health care regimen; any weight loss program, exercise, training regime or any diet. Our services are not intended to diagnose, treat, cure or prevent any disease.

Custom Fitness Consulting    Olathe, KS 66061    913-815-8819
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