| How long ago was your last physical? |
|
Has a physician ever advised you against exercise or given you any restrictions?
|
NO
YES,
please explain:
|
| Have you ever suffered any injuries or been diagnosed with any other orthopedic problems? |
NO
YES,
please explain:
|
| How do you rate your over-all health? |
|
Consumption of:
Alcohol
times/week
Caffeine
times/week |
Nicotine/Tobacco
times/week
Other
times/week
|
| Briefly
describe your job and the physical requirements of it. (i.e.
office worker, primarily sedentary) |
|
| Describe
your reasons for seeking a personal trainer? |
|
Excercise and Nutritional History |
| What
are your immediate fitness and nutritional goals? What
would you like to accomplish with a trainer in the next 3-4
months? |
|
| What
are your long term fitness and nutritional goals? Where
would you like to be a year from now and beyond? |
|
Have
you experienced success with in the past with diet or
exercise?
|
NO
YES,
please describe:
|
| What fitness facilities have you belonged to in the past or are currently a member of? |
|
| If you have ended your membership to a fitness facility in the
past, what was the reason? |
|
Have
you ever worked with a personal trainer before?
|
NO
YES, Who,
and for how long?:
|
Have
you ever worked with a nutritionist?
|
NO
YES, Who,
and for how long?:
|
Do
you participate in any sports or athletic hobbies (tennis, golf,
skiing, etc.)?
|
NO
YES, Describe:
|
Describe your current exercise program: |
| How would you rate your current exercise dedication? |
|
How
many days per week do you participate in weight training or pilates? |
|
| How
many days a week do you participate in cardiovascular training? |
|
| Describe what type
of cardiovascular activity and for how long to you participate. |
|
| How
many minutes per week do you devote to stretching or yoga? |
|
Describe your current nutritional habits: |
| How would you rate your
current nutrition? |
|
| How
many meals a day do you eat? |
|
| How
many times a week do you eat out? |
|
| Of
the times per week that you eat out, how many would be at what
would be considered a fast food restaurant? |
|
Do
you experience cravings for foods that you consider to be
unhealthy? If so please describe what types of foods
(sweets, salty, fatty, etc.).
|
NO
YES,
please describe:
|
| What are the most convenient days and times for you to meet with your
trainer? (You may select several with CONTROL-CLICK) |
|
|
|
| What days and times are completely not possible for you? |
|
|
|
| I
want to meet with my trainer: |
|