October 4, 2016 admin Fitness Assessment Fitness Assessment Name Business Email Phone Number Date of Birth: Age: Gender: Male Female Marital Status: Single Married Divorced Do you have any children? Yes No 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? Yes No Not sure Do you currently hold a health club/gym membership? Yes No If yes, how far from work and/or home is it located? less than 5 miles 5 - 10 miles 10 miles or more Do you feel your neighborhood is safe? Yes No What is your current occupation? Are you happy with your current occupation? Yes No Does the nature of your occupation require you to sit most of the day? Yes No Part of the day Does your occupation require you to travel? Yes No If yes, how often do you travel? less than 1 week a month 2 - 4 weeks a month months at a time Please detail your exercise history using Exercise, Intensity, Duration, and Frequency to describe. 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. Current Exercise: Intensity: 1 2 3 4 5 6 7 8 9 10 Duration: 1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours Frequency: once a week twice a week 3 times a week 5 times a week daily Past 12 months Exercise: Intensity: 1 2 3 4 5 6 7 8 9 10 Duration: 1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours Frequency once a week twice a week 3 times a week 5 times a week daily Past 5 years Exercise: Intensity: 1 2 3 4 5 6 7 8 9 10 Duration: 1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours Frequency: once a week twice a week 3 times a week 5 times a week daily Past 10 years Exercise: Intensity: 1 2 3 4 5 6 7 8 9 10 Duration: 1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours Frequency: once a week twice a week 3 times a week 5 times a week daily Other current daily/lifestyle activities (gardening, housework, yard work): Fitness/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? Treadmill Outdoor Running Stationary Bike Outdoor Cycling Walking Aquatics Aerobics Elliptical Pilates Yoga Flexibility Resistance Training Others How much time would you like to dedicate to your physical activity? Days per week for activity: 1 2 3 4 5 6 7 Time alloted per day: 1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours Please provide the following information if known. Height: Weight: Ideal weight: Least you have weighed your adult life and when: Most you have weighed your adult life and when: Circumferences (inches) Waist: Hip: Neck: Bicep (R): Thigh (R): Calf (R): Resting heart rate: Resting blood pressure: Nutrition Do you eat breakfast everyday? Yes No Do you eat 3 meals a day? Yes No If not, how many meals a day? less than 1 2 4 5 or more Do you snack throughout the day? Yes No If yes, what do you like to snack on? Do you find yourself skipping meals often? Yes No If yes, how often and which meals do you skip? less than once a week 2 - 4 times a week daily breakfast lunch dinner Do you get a variety of fruits and vegetables everyday? Yes No Approximately how many cups of fruit and vegetables do you consume everyday? less than 2 2 - 4 5 or more On average, how many alcoholic beverages do you consume per day? none 1 - 2 3 or more per week? none 1 - 2 3 - 4 5 or more Do you typically choose whole grain food sources versus refined food sources (i.e. brown rice vs. white rice)? Yes No Are you consciously limiting the intake of any of the following: salt saturated fat caffeine cholesterol red meats trans fats fried foods sugar no How many days a week do you eat fried food? less than 2 2 - 4 5 or more How many times a week do you eat away from home? less than 1 2 - 4 5 or more Where do you eat when away from home (mark all that apply)? fast food car sit down restaurant airport other What are your typical food choices when eating away from home (mark all that apply)? fish poultry pork red meat other Have you been on a special diet recently? Yes No If yes, which one? Have you ever kept a food log? Yes No If yes, what type? handwritten app Do you have any medical limitations to your diet? Yes No 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? Yes No Would you like to improve your diet or learn more about how to develop a heathly diet? Yes No If yes, how committed are you on a scale of 1 - 10? 1 2 3 4 5 6 7 8 9 10 If you have any specific nutrition goals, please detail below: Do you often feel stressed? Yes No If yes, on average how many days per week? less than 2 2 - 4 5 or more Does stress sometimes interfere with your health, personal happiness, or ability to be productive at work? Yes No Is your job often stressful? Yes No 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: 1 2 3 4 5 Do you get 7 - 8 hours of sleep on a regular basis? Yes No Would you consider the sleep you get quality sleep? Yes No Are you sometimes unable to relax when you want to? Yes No What are some ways that you relax/de-stress? Have you ever tried exercising as a de-stressor? Yes No 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: Please select your answer over eat under eat eat the same When you are stressed do you typically: Please select your answer over exercise under exercise exercise the same When you are stressed do you typically: Please select your answer gain weight lose weight maintain the same weight Please list any specific goals related to stress management below: Does your family have a history of any of the conditions listed below (mark all that apply)? Cardiovascular Disease: personal father mother grandfather grandmother uncle aunt sibling spouse n/a Stroke: personal father mother grandfather grandmother uncle aunt sibling spouse n/a High Cholesterol: personal father mother grandfather grandmother uncle aunt sibling spouse n/a High Blood Pressure: personal father mother grandfather grandmother uncle aunt sibling spouse n/a Diabetes: personal father mother grandfather grandmother uncle aunt sibling spouse n/a Lung Disease: personal father mother grandfather grandmother uncle aunt sibling spouse n/a Cancer: personal father mother grandfather grandmother uncle aunt sibling spouse n/a Do you currently use tobacco products? Yes No If yes, how long have you been smoking? less than 1 year less than 5 years 5 - 10 years 10 or more years how many times per day? less than once 2 - 4 5 or more If you have used tobacco products in the past, when did you quit? never used less than 1 year ago less than 5 years ago 5 - 10 years ago 10 or more years ago Are you exposed to second hand cigarette smoke? Yes No If yes, in what environment? Muscle issues: past present n/a Bone issues: past present n/a Joint issues: past present n/a Please list any other limitations, pain, discomfort, or concerns: Please list any current medications. Medication: purpose: dosage: how long: Medication: purpose: dosage: how long: Medication: purpose: dosage: how long: What 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: Time's up
