Houston Personal Trainer

Houston Personal Trainer : Mandy Fonville

Toll Free:
(888)MANDY-88
Email: Mandy@MyTrainerMandy.com

HOUSTON, TEXAS

Feel free to call, email, or use the contact form below.

You do not have to fill out the entire form; however, please include your name, phone, and email.

Name

Yes No

Email Address

Address

City, State, ZIP

Profession

Date of Birth

(MM/DD/YYYY)

Cell Phone Number

Work Number

Favorite exercise

Do you have any special requests?

I rate my current fitness level as a (1-10), ten being high.

I was specifically referred by:

How did you hear about us?:

Please specify publication / website / friend or other referral:

Do you consider yourself a healthy eater?

Yes No

If you answered "No", what do you tend to eat:

My main goal is:

Emergency Contact

Name:

Phone:

What are your goals?

Have you tried other personal trainers in Houston?

MEDICAL HISTORY (If you are a returning client, only complete the sections that have changed.)

1. Are you allergic to any medication (aspirin, penicillin, etc.)?

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

3. Do you have a seizure disorder (epilepsy)?

4. Do you have diabetes Adult or Juvenile?

5. Have you ever been found to be anemic (low blood count)?

6. Do you have High Blood Pressure (hypertension)?

7. Do you have asthma?

8. Do you have or have you ever had the following diseases?

Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:

9. Have you ever had a severe neck injury? Describe:

10. Have you ever been knocked out? Describe:

11. Do you wear glasses or contact lenses?

12. Have you had a broken bone or fracture in the past 2 years? Describe:

13. Have you ever injured your back? Describe:

14. Do you have back pain?

15. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:

16. Do you have other physical conditions which cause pain? Describe:

17. Detail any surgical procedures:

18. What are your goals for the next three months?

19. Have you had your body fat tested?

If yes, what percent is it?

20. Are you training for a specific event? If yes, explain:

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