Erin Cowton | 289-878-5418 | Email

BELIEVE IT • ACHIEVE IT • ONE WORKOUT AT A TIME ...

 

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Initial Consultation is FREE.
Call 289.878.5418 to book an appointment.

Online Training Registration

Online Training Registration Form

Please complete this information form before starting your custom designed fitness training program.

Full Name:
Street Address:
City:
Postal Code:

*Email:

Home Phone:

Mobile Phone:
Birthdate:
Sex:
Present Weight:
Height:

Diet and Exercise
How did you hear about my services?
Are you currently exercising regularly? Yes No
If yes, how long have you been exercising regularly?

Describe your cardiovascular exercise, what you do, how long, at what intensity and how many times per week.

Describe your resistance exercise, days per week, hours per day, exercises, average sets, reps and weight used.

Tell me about any extra activities you do, what they are, how long, how many times per week (golf, soccer etc).
What is your goal weight and or body fat?

Describe any sports you competed in as a kid, teen and at what level, approximately years and how long.

Describe your daily average activity including work and hobby, house chores etc.

How many days per week are you willing to exercise to achieve your goals?
At which intensity do you want to exercise?

Please list fully any injury or surgeries and dates.

How many meals per day do you consume?
How many snacks per day?

Describe your average breakfast.

Describe your average lunch.

Describe your average dinner.

Describe your snacks.

What are your food issues or foods you will not eat, if you have any? (over eat, under eat, night eater, carb craver etc)

Have you ever had or still have eating disorders? If yes please explain with dates.

Have you tried any diets or been on any weight loss plans, if so please describe what and when, and your results.

Do you drink? if yes please describe how much and how often.

Do you smoke? if Yes, how often?
How many hours of sleep do you average per night?

Please describe all your goals (examples are fat loss, muscle gains, injury rehab, sport or contest, wedding) and if you have a due date for your goal please indicate this as well. Also any other info you wish to include regarding diet and exercise.

History of heart problems, recurring chest pain, heart murmur, or stroke.
Diabetes Mellitus
Yes No
Asthma, breathing or lung problems
Yes No
Cancer (other than skin)
Yes No
Gallbladder disease or intestinal problems
Yes No
Back problem, joint or muscle disorder still affecting you
Yes No
Recent surgery (last 12 months)
Yes No
Hernia or any condition that may be aggravated by lifting weights
Yes No
Physician's advice not to exercise
Yes No
Are you pregnant, lactating or anticipating becoming pregnant? Yes No

If yes to any HEALTH question above, give a brief explanation.
History of total Cholesterol greater than 240 mg/dl
Yes No
Family history of coronary heart disease or other atherosclerotic disease in parents or siblings before age 55
Yes No
Disclaimer: I understand that participating in any program of exercise, nutrition and lifestyle change has certain risks. I realize that the information I provide is to determine my potential risk category and to provide a subsequent exercise and nutrition program. The information I have supplied is correct to the best of my knowledge. I also acknowledge that all participants in any program should consult their physician before embarking on such a program. I take full responsibility for my participation in any of these programs for any claims for injuries or illness that may result from my participation in any of their programs.
Yes No

Thank You!