Name:

Phone #:

E-Mail:

Male
Female

 Weight:

Height:

What time of day should we contact you? Please Select Morning Afternoon Evening
What Location do you prefer? Please Select South Tampa New Tampa Special Request (residence-park-office)
How did you hear about us? Please Select Current member Friend Flyer Online search Business Other

(Current physical activity)

How often do you exercise per week?

1-3 times
3-5 times
5-7 times
Never

Do you have any exercise barriers? Lack of motivation, social support, prior injury or existing, lack of confidence, none other

(Dietary Patterns)

How many meals (including snacks) do you have per day?

1
2-3
3-5
6 or more

On average, how long do you go between meals?

1 hr
2 hrs
3 hrs
more than 4hrs

(Exercise time)  

Which time is most ideal for your training?  
5:30-8am 4pm - 8pm other

Which three days of the week do you prefer to train?
Mon-Wed-Fri Tue-Thur-Sat other days Select Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday

 
(Goals)

Check all specific reasons that apply for entering this fitness program.

 physician recommended train for the specific event sport  job  look and feel better need motivation looking to motivate others promote teamwork improve posture increase energy increase speed increase strength increase cardiovascular endurance weight loss  improve body composition learn proper form technique, and modes to exercise  build or tone muscle  improve diet injury rehab increase flexibility reduce stress stop smoking reduce back pain prevent health risks  other

Physical Activity Readiness Questionnaire
PAR-Q

YES NO

1. Has your doctor ever said you have heart trouble?
2. Do you frequently have pains in your heart and chest?
3. Do you often feel faint or have spells of severe dizziness?
4. Has a doctor ever said you have high blood pressure?
5. Has your doctor ever told you that you have a bone or joint problem, such as arthritis?
6. Is there a good physical reason not mentioned here why you should not participate in activities?
7. Are you over age 65 and not accustomed to vigorous exercise?

Thank you for completing the first section of your personal assessment. Within 24hrs a Driven team member will contact you to schedule the physical portion of your assessment. Your complete assessment will help us find the program that best suits your needs. 

We look forward to training with you.