Personal Profile Form

You are about to change your life forever. The information you provide in your Personal Profile Form will be kept in the strictest confidence. Please be specific.

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
High Blood Pressure Low Blood Pressure Diabetes Coronary Heart Disease High Cholesterol / Triglycerides Angina (Chest Pain) Stroke Blood Clots Osteoporosis Circulatory Disorders Shortness of Breath Dizziness / Fainting Asthma / Chronic Bronchitis Thyroid / Anemia Disorders Gastro-Intestinal Disorders Urinary / Reproductive Disorders Spine or Disc Disorders Bone or Joint Disorders
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	Never 1 2 3 4 5 6 7 8 9 10
Alcohol	Never 1 2 3 4 5 6 7 8 9 10
Cigarettes / Tobacco	Never 1 2 3 4 5 6 7 8 9 10
Refined Sugars	Never 1 2 3 4 5 6 7 8 9 10
Fruits / Vegetables	Never 1 2 3 4 5 6 7 8 9 10
Lean Protein	Never 1 2 3 4 5 6 7 8 9 10
Sweets	Never 1 2 3 4 5 6 7 8 9 10
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.