| |
| Name | |
| Address | |
| Phone | |
| Work Phone | |
| Cell Phone | |
| Email | |
| Birthdate (yy,mm,dd) | |
| Height | |
| Weight | |
Has a physician ever advised you against exercise? |
| Yes No | Explain
|
Family Physician |
| Name | |
| Address | |
MEDICAL HISTORY
|
Explain any health problems, medicine taking and dosage, therapies currently undergoing |
| | |
Have you ever had any of the following? Check where necessary |
|
| Are you pregnant? | Yes No months |
| Have you been through a pregnancy? |
| | Yes No |
| How many? | |
| Any difficulties experienced? | |
Do you have any current injuries? |
| Yes No | Explain
|
Have you had any previous injuries / surgeries (ligaments, tendons, joints, muscles, discs, bone)? |
| Yes No | Explain
|
Rate your overall health
(1-10) | |
ATHLETIC HISTORY
|
| Sport or Activity Involvement | |
| Number of Years | |
| Level of Participation | |
| Type of Training | |
| Number of Times per week | |
| Are you currently training for a specific event, occasion or sport? |
| | Yes No |
LIFESTYLE
|
| Nutritional Habits (choose the appropriate number to reflect the number of times per day) |
| Water | |
| Alcohol | |
| Cigarettes / Tobacco | |
| Refined Sugars | |
| Fruits / Vegetables | |
| Lean Protein | |
| Sweets | |
| Do you have a nutritionist? |
| | Yes No |
|
| Rate your perceived ability in the following areas (1-10) |
| Diet | |
| General Fitness | |
| Flexibility | |
| Aerobic Fitness | |
| Strength | |
| How many leisure hours do you spend per day? | |
|
| Rate the following (1-10) |
| Stress Levels | |
| Psychological Wellness | |
| How well you cope with stress | |
| Energy Levels in the morning | |
| Energy Levels in the afternoon | |
| Energy Levels in the evening | |
|
| Can you pinpoint what stresses you? | |
| How do you relax? | |
| Do you get sick often (colds/flu)? |
| | Yes No |
| How many colds / flu have you had in the past year? |
| | |
| Does it normally take a long time for you to recover from a bout with the flu or a cold? |
| | Yes No |
| On average, how many hours of sleep do you get per night? |
| | |
| Do you awake feeling well rested and alert? |
| | Yes No |
|
Occupation
|
Do you sit at a desk / computer?
Yes No How Long? |
Nature of Occupation |
| Physical Stressful | Other:
|
If you currently participate in an exercise program...
|
| Weight Training / Body Sculpting | Days per week |
| Any Cardiovascular Activity | Days per week |
| Time spent stretching | |
Have you formerly participated in an exercise program? |
| What Nature | |
| How long | |
| Reason for discontinuing | |
| Hours per week | |
| Preferred time of day | |
| Number of times per week you would like to meet with your trainer |
| | |
Please explain a typical day in your life |
|
What motivates you? |
|
What are you passionate about? |
|
What are your health / fitness strengths and weaknesses? |
|
What are your greatest health / fitness accomplishments? |
|
Do you own home gym equipment? |
| Yes No | Explain
|
Are you currently a member of a health club? |
| Yes No | Explain
|
Have you ever worked with a personal trainer before? |
| Yes No | Name of facility/trainer
|
| Why would you hire a personal trainer? |
|
| How important is it to you to improve your health? |
| | Very Moderate Not |
| How important is it to you to improve your fitness? |
| | Very Moderate Not |
| Which is more important for you to improve? |
| | Health Fitness Equal |
| Rate your personal body image (1-10) |
| | |
What are your health and fitness interests and goals? Please be specific as to immediate and long term.
I would like to learn more about:
|
| Abdominal / Core Training:
low back care, rehab, therapy ball training, other |
| Adventure Fitness:
seals, cycle, other outdoor events |
| Balanced Nutrition:
Royal Bodycare products & diet-supplements, nutraceuticals, vitamins & minerals, custom eating plans, guided supermarket tours |
| Beginner Running Club:
running clinics, triathlon/marathon coaching |
| Cardiovascular Programs:
post-cardiac, high blood pressure, other |
| | Conditioning Programs: |
| Combat: boxing, kickboxing, self-defense, plyometric |
| Sport Specific: golf, tennis, ski, active rehab, outdoor, peri-natal, seniors |
| Digital Imaging:
corrective exercise, exercise therapy, body tracking |
| Exercise Programs:
home, self-directed, weight loss |
| Fitness/Sports Performance:
all sports & competions |
| Flexibility:
trainer assisted stretching, pilates, movement training |
| Golf:
swing enhancement programs, abdominal & core training |
| Rehab:
treatment plan preparation, active rehab programs, claim management, massage |
| Strength Training:
peri-natal, seniors, sport-specific,general fitness, other |
| Other Studio Features:
e-train, e-journal, massage, affiliated fitness partners |
|
Any additional comments? |
|
|
| Give comp session to: | |
| Name | |
| Address | |
| Phone | |
| Email | |
Thank you for taking the time to tell us about your self. The information you have provided will help us plan, organize and customize your training program before we meet. |
| |
