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All information received on this form will be treated as strictly confidential. Please fill out the forms as accurately as possible as this information is essential for catering to your specific needs, developing the safest, and most effective program possible.
 
*First Name:
Last Name:
City:
Address:
*Home Phone:
Work Phone:
Fax:
Web Site:
*Male:
*Email:
*Female:
Height:
Weight:
Age:
*Date of Birth:
(DD-MM-YYYY)
assessing your needs  

R.H.R.(Resting Heart Rate)
Do this question if you have time, but don’t worry too much if you don’t have time.
Take your pulse for 10 seconds or one minute, preferably first thing in the morning at rest without coffee or food
R.H.R.= beats per min.  
   
On a scale of 1 - 10, how would you rate your present fitness level?
1= Worst Ever, 10 = Best Ever. Your level =
   
How often do you take part in physical activities?
1-2 x week     3-4 x week 5-7 x week not in the past six months
about you  
If your participation is minimal, what are the reasons? ie: lack of interest, illness, injury,
explain:
 
Do you smoke?     yes =      no = If yes, how many per day
   
Do you take any medications either prescription or non-prescription on a regular basis?
If so, what? frequency:
dosage:      What is the medication for:
 
How does this medication affect your ability to exercise:
cardio and or sports
What activities are you presently involved in? ie: soccer, tennis , running
1)
Frequency/week:
 easy = moderate = hard =
Average length: 
 
2)
Frequency/week:
easy = moderate = hard =
Average length: 
 
3)
Frequency/week:
easy = moderate = hard =
Average length: 
 
 
Description:
Frequency/week:
easy = moderate = hard =
Average length: 
 
List exercises:
Stretching:
Frequency/week:
easy = moderate = hard =
Average length: 
 
 
How often a week would you like to workout? Please specify the days and times:
Monday:
Time: please include am &/or pm
Tuesday:
Time:
Wednesday:
Time:
Thursday:
Time:
Friday:
Time:
Saturday:
Time:
Sunday:
Time:
   
List in order of priority what fitness goals you would like to achieve in the next 3-6 months:
a)
b)
c)
   
List in order of priority what you expect from a Personal Fitness Trainer to help you achieve your goals?
a)
b)
c)
 
How many meals & or snacks do you eat per day?
Estimate how many calories you eat per day?  
How many glasses of water do you drink a day?     
Are you a vegetarian, if yes, do you combine certain foods to make a complete protein?
ie:
   
List your nutritional goals you would like to achieve in the next 3 – 6 months:
a)
b)
c)
In life, at times, we tend to be our own worst enemies, outline below what you feel your Potential activities, actions or behaviors that could impede your progress towards accomplishing your goals (ie: not training consistently or following the program)
Please mark Yes or No to the following:  
yes = no = Do you frequently have pains in your chest and heart?
yes = no = Has your doctor ever said you have heart trouble?
yes = no = Do you have any family history of heart disease or any other major illness or disease?
yes = no = Has your doctor ever said your blood pressure was too high?
yes = no = Do you suffer from a bone, joint or other problem that might be aggravated by physical activity?
yes = no = Do you suffer from any illnesses/diseases? (ie, diabetes, epilepsy, respiratory ailments etc.)
yes = no = Have you or do you suffer from any injuries? Back problems?
yes = no = Are you pregnant now or within the last 6 months?
yes = no = Are you on any medication?
yes = no = Have you had recent surgery?
 
If you have marked YES to any of the above, please elaborate below:
Please press the submit button to enter the form into the database.That will take you to the Thank You page with further instructions.