Personal Questionnaire

Please fill out this questionnaire as detailed as possible. This helps Belinda develop a workout program for your individual goals.

Today's Date (required)

Title
 Dr. Mr. Mrs. Ms. Miss

Your First Name (required)

Your Last Name (required)

Your Email (required)

Age (required)

Birth Date

Address

City

Phone (Home)

Phone (Work)

Phone (Cell) - (required)

Occupation

Gender
 Female Male

Height (required)

Weight (lbs) - (required)

Person to contact in case of Emergency Tel

Physician’s Name
Tel

What type of equipment do you have or have access to? For example, treadmill, stationary bike, dumbbells, workout ball, skipping rope or tubing. Please list all items below.

Medical History

Please indicate if any of these statements apply to you by selecting YES below

1. History of heart problem (i.e. Chest pain, heart murmur, or stroke)
   NoYes Past or Current ---PastCurrent
2. Diabetes Mellitus
   NoYes Past or Current ---PastCurrent
3. Asthma, breathing, or lung problems
   NoYes Past or Current ---PastCurrent
4. Allergies
   NoYes Past or Current ---PastCurrent
5. Cancer (other than skin)
   NoYes Past or Current ---PastCurrent
6. Seizures, seizure medication, neurological problems, dizziness
   NoYes Past or Current ---PastCurrent
7. High blood pressure
   NoYes Past or Current ---PastCurrent
8. Back problems, joint or muscle disorder still affecting you
   NoYes Past or Current ---PastCurrent
9. Recent surgery (last 12 months)
   NoYes Past or Current ---PastCurrent
10. Hernia or any condition that may be aggravated by exercise
    NoYes Past or Current ---PastCurrent
11. Physician’s advice not to exercise
    NoYes Past or Current ---PastCurrent
12. History of high cholesterol
    NoYes Past or Current ---PastCurrent
13. Family history of coronary heart disease?
    NoYes Past or Current ---PastCurrent
14. Do you smoke tobacco products
    NoYes Past or Current ---PastCurrent
15. Do you consume alcohol?
    NoYes Past or Current ---PastCurrent
16. Do you take supplements of any kind?
    NoYes Past or Current ---PastCurrent
17. Are you on medication?
    NoYes Past or Current ---PastCurrent
18. Do you have joint problems that might be aggravated by exercise?
    NoYes Past or Current ---PastCurrent
19. Is stress from daily living an issue in your life?
    NoYes Past or Current ---PastCurrent

Skeletal Injuries

Back

Neck

Head

Knee(R, L)

Shoulder(R, L)

Other injuries:

Surgery

Please describe any special considerations or how your injury currently affects your ability to function: (i.e. Illness or Injury)

Please talk with your doctor by phone or in person before you start any new training program or have a fitness assessment. Tell your doctor about your health questionnaire and which questions you answered yes.

Goals

1. What are your concerns and general goals? For example: fat loss, strength, power, muscular endurance, cardio fitness, flexibility, agility, core stability or balance)
   
2. Why do you want to achieve these goals? (Examples: general health, injury prevention/rehab, sport –specific training, aesthetic reasons)
   
3. What areas do you want to concentrate on or emphasize? (i.e. specific areas to strengthen, joint stability, cardio or core conditioning)
   

How can a Personal Trainer help you? Please check that which applies.

 Lose Body Fat Develop Muscle Tone Rehabilitate an Injury Nutrition Education Start an Exercise Program Design a more advanced program Safety Sports Specific Training Increase Muscle Size Fun Motivation

1. Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months?
   a)
   b)
   c)
2. How will you feel once you’ve achieved these goals? Be specific.
   
3. Where do you rate health in your life?
    Low Priority Medium Priority High Priority
4. How committed are you to achieving your fitness goals?
    Very Semi Not very
5. What do you think the most important thing Belinda can do to help you achieve your fitness goals?
   
6. 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, not following the program, allowing other responsibilities to become a priority over exercise, etc.).
   
7. Outline 3 methods that you plan to use to overcome these obstacles:
   a)
   b)
   c)

Fitness History

1. How long has it been since you have exercised regularly? (2 or more times/week).
   
2. Do you have experience with free weights or functional stability training?
   
3. What type of cardiovascular exercise are you familiar with?
   
4. If you are an experienced exerciser or athlete, what exactly is your current program?
   
5. Are there any exercises that are contraindicated or not recommended by your physician or physical therapist?
   
6. How would you describe your level of daily activities? Please check one.
    Light (office work) Moderate( Manual labor) Heavy (construction)
7. Stress (high=5, low=1) please select one.

   Physical
   Personal / Emotional:
   Mental / Career

8. Present method of handling stress:
   
9. Number of hours of sleep per night on average?
   
10. What is your available time and frequency for exercise?
    What days: ---MondayTuesdayWednesdayThursdaySaturdaySunday
    What times: AM PM
11. Any special considerations or requests?
    

Readiness

Belinda generally knows within a few minutes whether a client will succeed easily or not. If a client accepts her recommendations for changes to their exercise or nutrition program immediately and unconditionally, we know we will achieve success easily. If a client begins to make excuses or give reasons they feel they will not be able to adhere to the program, we can generally expect struggles throughout the process. We supply the following questionnaires to clients to help us determine where they are on the readiness scale. If you score low, this may not be the best time for you to initiate major changes to your lifestyle. It does not mean, however, that you cannot begin an exercise program. You can still initiate the program and start to develop patterns, but you should have lower expectations of yourself. If you score moderately, expect a few struggles on route towards your goals. If you score high, this is the perfect time for you to begin taking action towards your goals.

Readiness Questionnaire I

1. Do you feel you are at some sort of health risk because of your current behaviours/lifestyle?
    Yes No
2. Do you feel that making lifestyle changes will improve your quality of life and decrease your risk of health-related disorders?
    Yes No
3. Do you view your health and fitness program as a lifetime goal rather than a short-term temporary goal?
    Yes No
4. Are you willing to get personally involved in planning a health and fitness program?
    Yes No
5. Are you willing to try different approaches?
    Yes No
6. Do you have the patience to accept success in small increments and deal with possible setbacks?
    Yes No
7. Are you willing to set realistic goals?
    Yes No
8. Are you willing to make lifestyle changes?
    Yes No

If you answered yes to all these questions, you are ready for action! If you said no to one or more of the questions, you might experience resistance as you begin to initiate many of the actions required to achieve your goals. It may be helpful for you to review what is re y important to you and learn more about the negative effects of your current behaviour and the benefits of change.

Readiness Questionnaire II

1. Compared to previous attempts, how motivated are you this time to adhere to your exercise program?
   Not at all Motivated Extremely Motivated
2. How certain are you that you will stay committed to an exercise program for the time it will take to reach your goal?
   Not at all Certain Extremely Certain
3. Considering all outside factors in your life-work, stress, family obligations etc. - to what extent can you tolerate the effort required to stick to a lifetime exercise and nutrition plan?
   Cannot tolerate Can tolerate easily
4. Think honestly about your goals. How realistic are they?
   Very unrealistic Very realistic
5. Do you fantasize about eating a lot of your favorite foods?
   Always Never
6. How confident are you that you can work regular exercise into your daily schedule, starting tomorrow?
   Not at all confident Extremely confident

Score: 6-12: Low motivation 13-25: Moderate motivation 25+: High motivation