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ABOUT
VAULTS
- Vault – Hers
PROGAMS
NUTRITION
BLOG
SHOP
CONTACT

FIRE-FIT-CPAT-PREP_WHITE_500

THANK YOU..!

...for enrolling in CPAT Training

Thank you so much for enrolling in the CPAT Training and Preparation Course. To ensure you receive the materials I'm sending to you... and, that I have your correct information, please complete the form below. Thanks again,

Steve

Information & Health History - CPAT

This form is a complete profile of your personal contact information as well as current physical condition and goals you wish to achieve. I very much appreciate you taking the time complete this form as fully as possible.

Date:*
MM slash DD slash YYYY
First Name:*
Last Name:*
Email:*

A copy of this form will be sent to this email address.
Phone:*
Date of Birth:*
Street Address:
City:
State /Province/Region:
Zip/Postal Code:
Have you ever retained a personal trainer or coach in the past?
- Yes
- No
If YES, approximate dates - Please describe your experience and if it met your expectations?
EMERGENCY CONTACT:
Contact:*
Phone:*
Relationship:
HEALTH HISTORY:
Did you receive a medical clearance from your physician prior to beginning your exercise program?*
- Yes
- No
Has your doctor ever advised you against exercise?*
- Yes
- No
If YES, please explain why.
Have you undergone any surgeries in the past year?*
- Yes
- No
If YES, please describe.
Do you have any areas of your body that limit you during exercise?
- Yes
- No
If YES, please describe.
Is this limitation constant or does it "come and go?"
- It is constant
- It comes and goes
What makes it better?
What makes it worse?
PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING:
- Heart Problems
- Chest Pain
- High Blood Pressure
- Asthma / Inhaler
- Fainting
- Hypoglycemia
- Arthritis
- Chronic Illness
- Smoking
- Muscle / Joint Problems
- Neck / Back Injuries
- Diabetes
- Thyroid Conditiion
- Pregnant
- Breathing Problems
- I HAVE NO MEDICAL CONDITIONS.
Other, not listed above. Please describe fully.
LONG TERM GOALS AND OBJECTIVES FOR YOU AND YOUR BODY:
Goal #1:
Goal #2:
Goal #3:
Goal #4:
Specific Body Areas: (ie; arms, legs, abs, glutes, etc.)
Specific Body Area #1:
Rank 1-10: (1 = "Not Happy" to 10 = "Happy")
Specific Body Area #2:
Rank 1-10: (1 = "Not Happy" to 10 = "Happy")
Specific Body Area #3:
Rank 1-10: (1 = "Not Happy" to 10 = "Happy")
Specific Body Area #4:
Rank 1-10: (1 = "Not Happy" to 10 = "Happy")
Captcha

Always consult your physician before beginning any exercise, nutrition and/or supplement program -- especially if you are taking any over-the-counter or prescription medications. The general information found on this website is not intended to diagnose or treat any medical condition or to replace any advice put forth by your healthcare professional.