Personal Fitness Questionaire


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Personal Fitness Questionaire

  1. 1. Mind & Body Fitness Management, LLC Tel: (866)924-8284 PERSONAL FITNESS QUESTIONNAIRE ASSESSING YOUR NEEDS: All information received on this form will be treated as confidential. Please fill out this questionnaire completely and accurately. This information is essential in the development of a program that will address your specific needs, goals, interest and is safe and effective. Name: ______________________________Date of Birth: ____/____/____Age:______ Address:______________________________________________________________ Phone: h) ____________________ (o) ____________________ Cell) ____________________ (fax) ____________________ Email address:______________________ Company: __________________________Occupation: _______________________________ Physician’s Name: _________________________Physician’s Phone: ____________________ Physician’s Address: ___________________________________________________________ What is your reason for investing in Personal Training? Please check all that apply. o Lose Body Fat Develop Muscle Tone o Rehabilitate an Injury Nutrition Education o Start an Exercise Program Design a more advanced program o Safety Sports Specific Training Increase Muscle Size o Fun Motivation
  2. 2. o Other PAR-Q FORM It is this company’s requirement that you complete a PAR-Q form prior to starting an exercise program. Please circle YES or No to the following: Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? YES/NO Do you frequently have pains in your chest when you perform physical activity? YES/NO Have you had chest pain when you were not doing physical activity? YES/NO Do you lose your balance due to dizziness or do you ever lose consciousness? YES/NO Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? YES/NO Are you pregnant now or have given birth within the last 6 months? YES/NO N/A Have you had a recent surgery? YES/NO If you have marked YES to any of the above, please elaborate below: _____________________________________________________________________________________ _____________________________________________________________________________________ __________________________________________________________ Do you take any medications, either prescription or non-prescription on a regular basis? YES/NO What is the medication for? _____________________________________________
  3. 3. How does this medication affect your ability to exercise or achieve your fitness goals? ____________________________________________________________________ Fitness History 1. When were you in the best shape of your life? ____________________________________________________________________ 2. Have you been exercising consistently for the past 3 months? YES/NO 3. When did you first start thinking about getting in shape? ____________________________________________________________________ 4. What has prevented your from reaching your fitness goals in the past? ____________________________________________________________________ 5. On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)? ____________________________________________________________________ Exercise Related Questions: Skip to next section if you are presently inactive. 1. How often do you take part in physical exercise? Please circle. 5-7x/week 3-4x/week 1-2x/week 2. If your participation is lower than you would like it to be, what are the reasons? Please circle. Lack of Interest, Illness, Injury, or Lack of Time Other 3. How long have you been consistently physically active for? ____________________________________________________________________________ 4. What activities do you currently engaged in? ____________________________________________________________________________
  4. 4. Goal Setting 1. Please list in order of priority 3 fitness-based goals you would like to achieve over the next 3-6 months? a) _________________________________________________________________________ b) _________________________________________________________________________ c) _________________________________________________________________________ 2. How will you feel once you’ve achieved these goals? Be specific. ___________________________________________________________________________ 3. What priority does health have in your life? Please circle. Low priority, Medium Priority, or High priority 4. How committed are you to achieving your fitness goals? Please circle. Very, Semi, or Not very 5. Outline any obstacles, potential actions, behaviors or activities that could limit your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise etc.). ____________________________________________________________________________ ____________________________________________________________________________ Thank you for choosing the Mind & Body Fitness Management to assist with your wellness goals!