Personal Trainer Doc.

Health and Lifestyle Questionnaire
Name: _______________________________________________________________________________ Date of Birth: __________________________________________________________________________ Address: ______________________________________________________________________________ Phone: _______________________________________________________________________________ E-mail: _______________________________________________________________________________ Preferred method of contact: _____________________________________________________________ Emergency contact name: _______________________________________________________________ Relationship: __________________________________________________________________________ Phone number: _________________________________________________________________________

PAR-Q FORM Please answer ‘YES’ or ‘NO’ to the following: Has your doctor ever said you have a heart condition and recommended only medically supervised physical activity? Do you frequently have pains in your chest when you perform physical activity? Have you had chest pain when you were not doing physical activity? Do you lose your balance due to dizziness or do you ever lose consciousness? 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 or neck problems, asthma, etc.) Are you pregnant now or have you given birth in the last six months? Have you had surgery in the last six months? If you have marked ‘YES’ to any of the above, please elaborate below: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Do you take any medications, vitamins or herbs, either prescription or non-prescription, on a regular basis? What is this medication for? _____________________________________________________________________________________________ Does this medication affect your ability to exercise or achieve your fitness goals? How so? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

LIFESTYLE RELATED QUESTIONS 1. Do you smoke? How much? _____________________________________________________________________________________________ 2. Do you drink alcohol? How many glasses per week? _____________________________________________________________________________________________ 3. How many hours of sleep do you regularly get per night? _____________________________________________________________________________________________ 4. Describe your job. Sedentary Active Physically demanding

5. Does your job require travel? _____________________________________________________________________________________________ 6. On a scale of 1-10, how do you rate your stress level? (1= low, 10 = very high) _____________________________________________________________________________________________ 7. List your three biggest sources of stress. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 8. Is anyone in your family overweight? Mother Father Siblings Grandparent Children

9. Were you overweight as a child? What age? _____________________________________________________________________________________________

FITNESS HISTORY 1. When were you in the best shape of your life? _____________________________________________________________________________________________ 2. Have you been exercising consistently for the past three months? _____________________________________________________________________________________________ 3. When did you first start thinking of getting in shape? _____________________________________________________________________________________________ 4. What, if anything, stopped you in the past? _____________________________________________________________________________________________ 5. On a scale of 1-10 how would you rate your present fitness level? (1=low, 10=best) _____________________________________________________________________________________________

NUTRITIONAL RELATED QUESTIONS 1. On a scale of 1-10 how would you rate your nutrition level? (1=very poor, 10=excellent) _____________________________________________________________________________________________ 2. How many times per day do you usually eat? (including snacks) _____________________________________________________________________________________________ 3. Do you skip meals? _____________________________________________________________________________________________ 4. Do you eat breakfast? _____________________________________________________________________________________________ 5. Do you eat late at night? _____________________________________________________________________________________________ 6. What activities do you engage in while eating? (T.V., reading, driving, etc.) _____________________________________________________________________________________________ 7. How many glasses of water do you drink per day? _____________________________________________________________________________________________ 8. Do you feel drops in your energy levels throughout the day? When? _____________________________________________________________________________________________ 9. Are you currently taking multivitamins or meal replacement supplements? Please list. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10. At work or school do you usually eat out or bring a lunch? _____________________________________________________________________________________________ 11. How many times per week do you eat out? _____________________________________________________________________________________________ 12. Do you do your own grocery shopping? _____________________________________________________________________________________________ 13. Do you do your own cooking? _____________________________________________________________________________________________ 14. Besides hunger, what other reason(s) do you eat? Boredom Happy Stress Nervous Social Other Tired Depressed

15. Do you eat past the point of fullness? _____________________________________________________________________________________________

16. List some areas of nutrition you want to improve. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ EXERCISE RELATED QUESTIONS 1. How often do you take part in physical activity? _____________________________________________________________________________________________ 2. If your participation is lower than you would like it to be, what are the reasons? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. How long have you been consistently physically active for? _____________________________________________________________________________________________ 4. What activities are you currently involved in? (please include frequency/week, duration, and level of difficulty) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

DEVELOPING YOUR FITNESS PROGRAM 1. Please circle how you prefer to exercise. Indoors Morning Outdoors Afternoon Combination Evening

2. Realistically, how often would you like to exercise per week? _____________________________________________________________________________________________ 3. Realistically, how often would you like to work with a trainer? _____________________________________________________________________________________________ 4. What are the best days of the week for you to be able to commit to an exercise program? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

GOAL SETTING 1. How can a personal trainer help you achieve your goal(s)? Please mark all that apply. Lose body fat Rehabilitate an injury Start an exercise program Safety Develop muscle tone Nutrition education Design a more advanced program Sports specific uraining

Increase muscle size Motivation

Fun Other: ______________________________

In order to increase your chances of being successful in achieving your goal(s), a certain protocol should be followed. Please ensure your goals are ‘SMART’ S= Specific (provide as much detail as you possibly can - how long, how much, etc.) M= Measurable (how do you know when you have reached your goal?) A= Attainable (be realistic, set smaller goals in order for you to achieve your big goal) R= Rewards (attach a reward to each goal) T= Time Frame (set a specific date for your goal to be achieved) Goal #1 S___________________________________________________________________________________________ M___________________________________________________________________________________________ A___________________________________________________________________________________________ R____________________________________________________________________________________________ T____________________________________________________________________________________________ Goal #2 S___________________________________________________________________________________________ M___________________________________________________________________________________________ A___________________________________________________________________________________________ R____________________________________________________________________________________________ T____________________________________________________________________________________________ Goal #3 S___________________________________________________________________________________________ M___________________________________________________________________________________________ A___________________________________________________________________________________________ R____________________________________________________________________________________________ T____________________________________________________________________________________________ 2. Where do you rate health in your life? Low priority Medium priority High priority

3. How committed are you to achieving your personal fitness goals? Very Semi Not very

4. What do you think the most important thing your personal trainer can do to help you achieve your personal fitness goals? (remember - we are here for YOU) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

5. Outline what you feel are the obstacles or your potential actions, behaviours or activities that could impede your progress towards accomplishing your goals. (i.e. not training consistently, upcoming vacation, busy season at work, allowing other responsibilities to get in the way of exercise, etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

6. Outline three methods that you plan to use to overcome these obstacles: A)___________________________________________________________________________________________ B)___________________________________________________________________________________________ C)___________________________________________________________________________________________

MISCELLANEOUS QUESTIONS 1. How did you hear about us? _____________________________________________________________________________________________ 2. If you were referred to us, who told you about our services? _____________________________________________________________________________________________ 3. Is there any other information that your trainer should be aware of? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________