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Medical & Exercise History Questionnaire

Thank you for taking the time to fill out our questionnaire, and please keep in mind, the more you tell us, the better job we can do individualizing your coaching experience. We look forward to meeting you, and will be contacting you as soon as possible.

  • Contact Information

  • If so, please check the box next to his or her name below.
  • Personal / Lifestyle Information

  • (enter here or type "discuss" if you would rather discuss in person.)
  • :
  • :
  • Exercise & Physical Activity History

  • (Exercise, for now can be defined as any consistent physical activity, i.e. walking, jogging, lifting weights, or rec sports lasting more than 30 minutes continually at a time.)
  • (Select all that apply)
  • (i.e. did you feel better or worse at the end of the workout?)
  • Physical Activity Readiness Questionnaire (PAR-Q)

    For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Please read and check the yes or no opposite the question.
    *If your health changes and answers above are altered, please notify your Fitness Coach, and we will discuss seeking guidance from a physician.
  • Medical History

  • (Click all that apply)
  • Goals & Motivation

  • We will work with you to fine tune any ideas or vision you have for what it is your are looking for. Please offer any insight as to what has motivated you to contact us and what you hope to experience working with us.
  • Commitment

  • (Give or take a day)
  • Nutrition

  • (A snack is considered a meal.)
  • (Cup of coffee = 100 mg , 12 oz soda = 50-60 mg , tablet = 200 mg)
  • Scheduling An Appointment / Availability

  • To match your goals with our programming and services, we offer the following choices. Please choose something that closely matches what you are envisioning, and we will further discuss this when we meet the first time. You are not committing to anything at this point, just giving us an idea on how to prepare for our initial few sessions so we can get on the same page that much sooner.
  • In the text box below, please tell us your available days and times of day that are good for you. This is very important to answer as it may determine what trainer is available during this time. Thank you.
  • Let me know if you have any other questions or comments.
  • Add a new row

Thank you for taking the time.