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Wellness questionnaire
Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Age
*
Gender
*
Male
Female
Weight
*
Height
*
What is your fitness level?
*
Beginner
Intermediate
Advanced
How many years have you been exercising?
*
How often do you do H.I.I.T? (High Intensity Interval Training)
*
What exercises do you do?
*
What exercises do you enjoy the most?
*
How many days in the week do you workout?
*
How many minutes is each workout?
*
What exercise equipment do you use?
*
What exercise equipment do you own?
*
What are your fitness goals?
*
Do you have any chronic illnesses?
*
Yes
No
If yes, please explain:
What foods make up your diet?
*
How many ounces of pure water do you drink daily?
*
On average, how many hours of sleep do you get each night?
*
Are you pregnant or nursing?
*
Yes
No
Have you ever given birth?
*
Yes
No
If yes, please specify if it was a natural birth or C-Section.
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are between the ages of 18 and 69, the following questions will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
If yes, please explain:
Do you feel pain in your chest when you do physical activity?
*
Yes
No
If yes, please explain:
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
If yes, please explain:
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
If yes, please explain:
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
*
Yes
No
If yes, please explain:
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
*
Yes
No
If yes, please explain:
Do you know of any other reason why you should not do physical activity?
*
Yes
No
If yes, please explain:
Please share any additional information about yourself that you feel is appropriate.
Which days work best for an appointment?
*
Monday
Tuesday
Wednesday
Thursday
Which time frames work best for an appointment? Please remember that we run on CENTRAL TIME ZONE
*
Times MUST be between 9:30 AM - 5:30 PM ONLY
Anytime between 9:30 AM - 12:30 PM
Anytime between 3:00 PM - 5:30 PM
I prefer a specific time
If you prefer specific times, please list them.
Physical exercise can be strenuous and you are subject to risk of injury. You agree that by participating in physical exercise, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements, weight reduction and/or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death. We are also not responsible for any loss of your personal property. You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge the trainer from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally.
*
Signature - Please type your full name:
Today's Date
*
MM
DD
YYYY
Thank you!
