Surge Fitness New York City's Premier Personal Training Service
  Surge Fitness - New York City's Premier Personal Training Service
 
 

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Personal Trainers
Jason Keigher
Urban Fitness
Amazingly Fit
Tri State Fitness
Fit Brides
The Fitness Edge
 
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New Client Sign Up Form


Surge Fitness is committed to finding you a compatible personal trainer, yoga instructor, pilates instructor, massage therapist or nutritionist. This questionnaire will help us understand your needs and goals. We can also be reached directly at 917-549-8998.

REQUIRED INFORMATION
Full Name:
Email Address:
Phone Number:

OPTIONAL INFORMATION
  
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:


HEALTH AND FITNESS GOALS
What are your health and fitness goals? (be very specific)
Are you trying to diet and lose weight? yes no
If yes, how much do you want to lose? lbs.

What areas of fitness interest you?  Strength training    Body Toning and Shaping
Weight Loss    Flexibility/Stretching    Yoga    Pilates    Body Building
Pre/Post Natal    Postural Correction    Nutrition    Other:


TRAINING LOCATIONS, TIMES AND DATES

Select the days you would you like to workout?  Sunday    Monday    Tuesday
Wednesday    Thursday    Friday    Saturday

What time of day would you like to workout?  6-9am    9am-12pm    12-3pm
3-6pm    6-9pm    9-11pm    Other:

Where will you workout? Gym/Health Club   Home    Other:

If you will workout at home, what type of equipment do you have?


EXERCISE HISTORY
Do you currently exercise on a regular basis? yes no
If yes, describe the frequency, intensity, time and type of exercise routine:


MEDICAL HISTORY
List any injury or medical condition that may limit your ability to follow a fitness program:


MISCELLANEOUS
List any additional information, including specific trainers that you'd like to work with:

Thank you for filling out this questionnaire. We will notify you when we receive your information. If we need additional information we will call or e-mail.