October 4, 2016

Fitness Assessment

Fitness Assessment

Name Business Email Phone Number

Date of Birth:



Marital Status:

Do you have any children?

If yes, how many and what are their ages?

Do you feel that you have a strong support network made up of family members and/or friends?

Do you currently hold a health club/gym membership?

If yes, how far from work and/or home is it located?

Do you feel your neighborhood is safe?

What is your current occupation?

Are you happy with your current occupation?

Does the nature of your occupation require you to sit most of the day?

Does your occupation require you to travel?

If yes, how often do you travel?

Please detail your exercise history using Exercise, Intensity, Duration, and Frequency to describe.stopwatch-153398_1280

Exercise- list the type of activity or activities that you participate in; the "work" that you are doing.

Intensity- how hard you perceive the work you do; rank how hard the work you do on a scale of 1 - 10, 10 being the hardest.

Duration- the length of time of each of your exercise sessions.

Frequency- the amount of times per week dedicated to exercise.






Past 12 months





Past 5 years





Past 10 years





Other current daily/lifestyle activities (gardening, housework, yard work):

tape-403593_1920Fitness/Wellness Goals

Short term goals (6 months or less):

Long term goals (6 months of more)

If different from what is listed above, what activities are you interested in now?

How much time would you like to dedicate to your physical activity?time-1485384_1920

Days per week for activity:

Time alloted per day:

Please provide the following information if known.



Ideal weight:

Least you have weighed your adult life and when:

Most you have weighed your adult life and when:

70070008Circumferences (inches)




Bicep (R):

Thigh (R):

Calf (R):

Resting heart rate:

Resting blood pressure:


Do you eat breakfast everyday?

Do you eat 3 meals a day?

If not, how many meals a day?

Do you snack throughout the day?

If yes, what do you like to snack on?

Do you find yourself skipping meals often?

If yes, how often and which meals do you skip?

Do you get a variety of fruits and vegetables everyday?

Approximately how many cups of fruit and vegetables do you consume everyday?

On average, how many alcoholic beverages do you consume per day?

per week?

Do you typically choose whole grain food sources versus refined food sources (i.e. brown rice vs. white rice)?

Are you consciously limiting the intake of any of the following:

How many days a week do you eat fried food?

How many times a week do you eat away from home?

Where do you eat when away from home (mark all that apply)?

What are your typical food choices when eating away from home (mark all that apply)?

Have you been on a special diet recently?

If yes, which one?

Have you ever kept a food log?

If yes, what type?

Do you have any medical limitations to your diet?

If yes, what are they?

What foods do you enjoy?

What foods do you enjoy, but feel you need to restrict?

Do you feel all foods can be eaten if in moderation?

Would you like to improve your diet or learn more about how to develop a heathly diet?

If yes, how committed are you on a scale of 1 - 10?

If you have any specific nutrition goals, please detail below:

lonely-1510265_1920Do you often feel stressed?

If yes, on average how many days per week?

Does stress sometimes interfere with your health, personal happiness, or ability to be productive at work?

Is your job often stressful?

If yes, in what way?

Rank the stress you experience in a typical day on a scale of 1 -5, 5 being extremely stressed and 1 being not stressed:

Do you get 7 - 8 hours of sleep on a regular basis?

Would you consider the sleep you get quality sleep?

Are you sometimes unable to relax when you want to?

What are some ways that you relax/de-stress?

Have you ever tried exercising as a de-stressor?

If yes, what did you do and was it effective?

List some factors that stimulate stress for you:

When you are stressed do you typically:

When you are stressed do you typically:

When you are stressed do you typically:

Please list any specific goals related to stress management below:

dna-1500071_1920Does your family have a history of any of the conditions listed below (mark all that apply)?

Cardiovascular Disease:


High Cholesterol:

High Blood Pressure:


Lung Disease:


Do you currently use tobacco products?

If yes, how long have you been smoking?

how many times per day?

If you have used tobacco products in the past, when did you quit?

Are you exposed to second hand cigarette smoke?

If yes, in what environment?

Muscle issues:

Bone issues:

Joint issues:

Please list any other limitations, pain, discomfort, or concerns:

headache-1540220_1920Please list any current medications.




how long:




how long:




how long:

physiotherapy-595529_1920What do you hope to gain by having a personal trainer?

What are your expectations of your personal trainer?

Anything else you would like to share that may be of benefit, please detail below: