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1 PERSONAL TRAINING Name: Date: Address: City: State: Zip: Birthday: / / Sex: Male Female Name of Gym: Occupation: Phone (home): Phone (work): Body Weight: Body Fat: Height: Personal Goals 1. Primary Training and Nutrition Objectives (check one or more) Fat Loss Strength Weight Loss Build Muscle Shape and Tone Injury Rehabilitation Sport-specific Training Reduce Stress 2. What areas of your body do you specifically want to work on? Increase Cardiovascular Endurance 3. Training Experience: Sedentary Beginner Intermediate Upper-Intermediate Advance Pre-Contest or Preseason 4. Do you presently engage in physical activity? What kind? How Often? 5. Are you currently participating in a structured resistance training program? For how long?
2 6. Are you currently participating in a structured cardio respiratory program? For how long? 7. How often will you workout per week (circle one) 3 (minimum) other 8. What kind of cardiovascular activity do you enjoy most? Elliptical Stationary Bike Stationery Rower Stair Climber Treadmill Aerobics Class Other Occupation 1. What is your current occupation? 2. Does your occupation require extended periods of sitting? 3. Does your occupation require extended periods of repetitive movements? 4. How many hours do you work or go to school? 5. On a scale from 1 to 10, what is your stress level? Personal? Habits 1. How many hours of sleep do you get per day? (average) 2. Have you ever suffered from insomnia? 3. How many meals do you eat daily? How many calories? 4. Do you eat meat? Favorite food: 5. Do you snack? Favorite snack: 6. Do you have any diet restrictions or allergies? If Yes: What? What Type?
3 7. Are you currently taking multivitamin, mineral or other type of food supplement? If yes: What are you taking? Why? 8. Do you smoke? If yes, how much? 9. Do you drink alcohol? If yes, how much? 10. Do you drink caffeine? Yes NO If yes, how much? 11. Are there any habits you would like to change? 12. Would you like to know what supplements would be integral to your success? Medical History Please check any of the following health problems you have or have been diagnosed with or treated by a health professional: Orthopedic Problems Heart Murmur Varicose Veins Injuries to back, High Blood Lung Disease Knees, ankles Pressure Brain concussion Heart Attack/ Rheumatic Head Injury Stroke Loss of Heart Rhythm Dizziness Consciousness Abnormality Epilepsy/Seizures Any type of Problems w/ Balance Heart Problem Vertigo High Stress Disease of Hypoglycemia Arteries Chest Pain Of any kind Asthma High Cholesterol Anemia Arthritis, what kind?
4 Diabetes, how long ago? Allergies, (hay fever etc.) Operations, what kind? 1. Old or recent injuries? 2. When was you last complete physical exam? 3. Are you currently taking medications? If Yes, What? 4. Is there any good reason not mentioned here why you should not follow an activity program even if you wanted to? Family History Have any of your blood relatives (brother, sister, parents, grandparents, aunts, uncles etc.) had: Heart Attack High Blood Pressure Congenital Heart Disease Heart Operation High Cholesterol Epilepsy Diabetes Other
5 Wildwood Family Clinic Waiver I, have read and understand, and answered the above health/medical survey questions fully and truthfully. I am aware of my responsibility to consult with my personal physician regarding my medical fitness to engage in strenuous exercise and a nutritional support program. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the participating training facility, and the fitness trainer administering this instrument for any and all injuries suffered while following the training and/or nutrition program provide to me. Client Signature Date: Print Clients Name: Parent/Legal Guardian Signature
FITNESS ASSESSMENT & WAIVER
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