Fitness Program Application Form

The other day, I was (gently) dobbed in by my wife to join an exercise program at the local gym. She thinks I’m getting too old and fat for her. We’re like Beauty and the Beast, she said. As part of joining up, I was given a form to fill in. Here’s my application and health questionnaire form including fitness assessment. Are you impressed at my fitness level? I’ve tried to be as accurate as possible.


First Name: Trainee

Surname:  Surgeon

DOB  _25/09/2001_      Occupation:   Social Media Activist

What would  your fitness level to be at this moment? Please circle closest number.

1        2       3        4       5         6        7       8       9      10      25 (incredibly fit)

(unfit)             (moderately fit)                     (very fit)

List any exercises you currently do and how often in a week

Type of exercise: Upper limb

Frequency/week: 3 times/day lifting BIG Macs

When was the last time you exercised: 1975

Which time of the day would you prefer to exercise: (Really, is this a serious question????)

  • early mornings    o late mornings    o  evenings  □ When I’ve got nothing else to do.

What would you most like to achieve in this fitness program:  Pls circle.

o Weight loss    o Muscle tone   o Cardiovascular fitness   o Flexibility     o General Wellbeing

  □ All round macho, macho man

Others not mentioned above: Really, all round macho, macho man

How hard would you like to work:     Please circle closest number

1          2           3             4             5             6            7             8              9            10

(not hard) (duh!)                   (moderately hard)                                    (very hard)

What are your health and fitness goals and when approximately would you like to achieve them?

My wife married me for my good looks. I would like to look even hotter for her. If possible within the week.

Would you like some guidance with your current eating pattern?    Yes       No, I’m happy with the local MacDonalds and KFC.

Are you pregnant?      Yes        No      NA     If   Yes, how many months? _

Are you trying to conceive?     Yes      Wife said NO!

Are you a smoker?    Yes      No     If yes, how many cigarettes a day?

Do you have any form of heart trouble?     Yes, my wife broke it the day I saw her.         No

If Yes, please detail type and symptoms: Palpitations, broken heart, hopeless romantic

(chest discomfort, unreasonable breathlessness, dizziness, fainting, blackouts)

Have you had high blood pressure  >140/90mmHg?   Yes, sometime during that honeymoon trip    No

If yes, are you BP medication?   Yes        No

Are you diabetic?      Yes         No, but I really am a sweet man.  

Do you have asthma?    Yes        No

Do you have epilepsy?   Yes        No

Do you have back problems?   Yes       No, but maybe after the exercise, yes.

Do you have any existing injuries?     Yes    No

If Yes, please describe briefly Severe generalised musculoskeletal pain after washing the dishes, laundry and vacuuming last week.

Do you take any prescription medication, pills, tablets or supplements?     Yes   No      If yes, please detail below:

If you have answered Yes to any of the above question, you may have to obtain medical clearance from your doctor before commencing exercise.