Fitness Questionaire
The first step in aquiring a personal trainer is to fill out the questionaire below then we will schedule a consultation. The Initial Consultation is free which includes reviewing the questionaire, analyzing goals, assesing where you are, discussing where you want to be and putting together the plan to get you where you there! We look forward to working with you. Let us know if you have specific questions.
FITNESS ASSESSMENT QUESTIONNAIRE
Please answer all questions accurately and honestly to allow us to fully determine your individual needs.
First Name:________________________ Last Name: ______________________________________
Address: _______________________________________ City: _______________ Zip: ___________
Phone: ________________________________________ Alt Phone: __________________________
Age: ______ Height: ______________ Weight: _______________ Ideal Weight: ____________
1. Have you been a Client of a personal trainer before? Yes No
2. Have you been exercising regularly for the past 6 months? Yes No
3. During your last program did your progress slow dramatically after the first few weeks? Yes No
4. Do you smoke? Yes No
5. Do you drink occasionally? Yes No
6. How long did you keep your last health club membership while not using the facility? ____ Months ____Yrs
7. How often do you eat out? __________ Times per week.
8. How often do you buy new clothes in an attempt to improve your self-image and/or confidence? _____ Times per month.
9. Please list the habits you would like to change: ________________________________________________________
__________________________________________________________________________________________________
10. What events in your life are coming up that will motivate you to reach your goals?
___________________________________________________________________________________________________
11. After reaching your goals, how will your life be different?
___________________________________________________________________________________________________
________________________________________________________
12. Over the past 10 years how many times have you started and stopped a nutrition and exercise regiment?
1 – 5 6 – 10 11 – 15 16 – 20 Too many to count
13. What external factors have derailed your progress in the past?
Time Money No facility Procrastination Lack of support
14. In your own opinion, why where you unable to “stick with it”?
Discipline Knowledge Experience Accountability Lack of expertise
15. I would like to:
Lose weight Gain weight Feel better Look better Live healthier
16. On a scale of 1 – 10, how serious are you about achieving your goals?
1 2 3 4 5 6 7 8 9 10
17. Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity? Yes No
18. Do you ever faint or get dizzy and lose your balance? Yes No
19. Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity? Yes No
If yes, explain _______________________________________________________________________________________________________________
20. Do you have high blood pressure or a heart condition in which a physician is currently prescribing a medication? Yes No
21. Do you have insulin dependent diabetes? Yes No
22. Is there anything else your trainer should be aware of?
RELEASE AND WAIVER OF LIABILITY CLIENT ACKNOWLEDGEMENT OF ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF NFS Natural Fitness Systems, LLC. acknowledges that the Personal Training/Fitness Assessment hereunder includes participation in strenuous physical activities, including but not limited to, cardio fitness, weight training, steppers, kicking bags and various resistance exercises (the “Physical Activities”). Client acknowledges these Physical Activities involve inherent risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and other
illness, soreness, or injury however caused, occurring during or after the Clients participation in the Physical Activities. Client further acknowledges that such risks include but are not limited to, injuries cased by the negligence of an instructor or other person, defective or improperly used equipment, over exertion of a Client, slip and fall by Client, or an unknown health problem of Client. Client agrees to assume all risk and responsibility involved with participation in the Physical Activities. Client affirms that Client is in good physical condition and does not suffer from any disability that would prevent or limit participation in the Physical Activities. Client acknowledges that participation will be physically and mentally challenging, and Client agrees that it is the responsibility of Client to seek competent medical or other professional advice regarding any concerns involved with the ability of Client to take part in the Physical Activities. By signing this Agreement, Client asserts that he or she is capable of participating in the physical activities. Client agrees to assume all risk and responsibility for exceeding his or her own physical limits. Client, on behalf of Client, his or her heirs, assigns the next of kin, agrees to fully release NFS Natural Fitness Systems, LLC (as well as any of its owners, related entities, employees or other authorized agents, including Independent Contractors) from any and all liability, claims and/or litigation actions that Client may have for injuries, disability or death or other damages of any kind, including but not limited to punitive damages, arising out of participation in the Physical Activities, including but not limited to the Personal Training/Nutritional Program and the Physical Activities, even if caused by the negligence, intentional acts or omissions and/or any other type of fault of NFS Natural Fitness Systems, LLC, it’s owners, employees or other authorized agents including Independent Contractors.
Client Signature: X______________________________________ Date: _________________
Medical Clearance Form
Dear Doctor:
Your patient _____________________________________________ wishes to take part in an exercise program and/or fitness assessment. The exercise program may include progressive resistance training, flexibility exercises, and a cardiovascular program; increasing in duration and intensity over time. The fitness assessment may include a sub-maximal cardiovascular fitness test and measurements of body composition, flexibility, and muscular strength and endurance.
After completing a readiness questionnaire and discussing their medical condition(s) we agreed to seek your advice in setting limitations to their program. By completing this form, you are not assuming any responsibility for our exercise and assessment program. Please identify any recommendations or restrictions for your patient's fitness program below (Physician's Recommendations).
Patient's Consent and Authorization I consent to and authorize __________________________________________ to release to NFS Natural Fitness Systems LLC., health information concerning my ability to participate in an exercise program and/or fitness assessment. I understand this consent is revocable except to the extent action has already been taken. Authorization is not valid beyond one year from date of signature. Further disclosure or release of my health information is prohibited without specific written consent of person to whom it pertains.
Client’s signature ___________________________________________ Date ___________
Parent signature if minor
Physician's Recommendations I am not aware of any contraindications toward participation in a fitness program.
I believe the applicant can participate, but urge caution because:
The applicant should not engage in the following activities:
I recommend the applicant not participate in the above fitness program.
Physician’s signature _______________________________________________Date _______________
Physician’s name (print)____________________________________________ Phone ______________
Address _______________________________________City ________________Zip ______________
FITNESS ASSESSMENT QUESTIONNAIRE
Please answer all questions accurately and honestly to allow us to fully determine your individual needs.
First Name:________________________ Last Name: ______________________________________
Address: _______________________________________ City: _______________ Zip: ___________
Phone: ________________________________________ Alt Phone: __________________________
Age: ______ Height: ______________ Weight: _______________ Ideal Weight: ____________
1. Have you been a Client of a personal trainer before? Yes No
2. Have you been exercising regularly for the past 6 months? Yes No
3. During your last program did your progress slow dramatically after the first few weeks? Yes No
4. Do you smoke? Yes No
5. Do you drink occasionally? Yes No
6. How long did you keep your last health club membership while not using the facility? ____ Months ____Yrs
7. How often do you eat out? __________ Times per week.
8. How often do you buy new clothes in an attempt to improve your self-image and/or confidence? _____ Times per month.
9. Please list the habits you would like to change: ________________________________________________________
__________________________________________________________________________________________________
10. What events in your life are coming up that will motivate you to reach your goals?
___________________________________________________________________________________________________
11. After reaching your goals, how will your life be different?
___________________________________________________________________________________________________
________________________________________________________
12. Over the past 10 years how many times have you started and stopped a nutrition and exercise regiment?
1 – 5 6 – 10 11 – 15 16 – 20 Too many to count
13. What external factors have derailed your progress in the past?
Time Money No facility Procrastination Lack of support
14. In your own opinion, why where you unable to “stick with it”?
Discipline Knowledge Experience Accountability Lack of expertise
15. I would like to:
Lose weight Gain weight Feel better Look better Live healthier
16. On a scale of 1 – 10, how serious are you about achieving your goals?
1 2 3 4 5 6 7 8 9 10
17. Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity? Yes No
18. Do you ever faint or get dizzy and lose your balance? Yes No
19. Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity? Yes No
If yes, explain _______________________________________________________________________________________________________________
20. Do you have high blood pressure or a heart condition in which a physician is currently prescribing a medication? Yes No
21. Do you have insulin dependent diabetes? Yes No
22. Is there anything else your trainer should be aware of?
RELEASE AND WAIVER OF LIABILITY CLIENT ACKNOWLEDGEMENT OF ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF NFS Natural Fitness Systems, LLC. acknowledges that the Personal Training/Fitness Assessment hereunder includes participation in strenuous physical activities, including but not limited to, cardio fitness, weight training, steppers, kicking bags and various resistance exercises (the “Physical Activities”). Client acknowledges these Physical Activities involve inherent risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and other
illness, soreness, or injury however caused, occurring during or after the Clients participation in the Physical Activities. Client further acknowledges that such risks include but are not limited to, injuries cased by the negligence of an instructor or other person, defective or improperly used equipment, over exertion of a Client, slip and fall by Client, or an unknown health problem of Client. Client agrees to assume all risk and responsibility involved with participation in the Physical Activities. Client affirms that Client is in good physical condition and does not suffer from any disability that would prevent or limit participation in the Physical Activities. Client acknowledges that participation will be physically and mentally challenging, and Client agrees that it is the responsibility of Client to seek competent medical or other professional advice regarding any concerns involved with the ability of Client to take part in the Physical Activities. By signing this Agreement, Client asserts that he or she is capable of participating in the physical activities. Client agrees to assume all risk and responsibility for exceeding his or her own physical limits. Client, on behalf of Client, his or her heirs, assigns the next of kin, agrees to fully release NFS Natural Fitness Systems, LLC (as well as any of its owners, related entities, employees or other authorized agents, including Independent Contractors) from any and all liability, claims and/or litigation actions that Client may have for injuries, disability or death or other damages of any kind, including but not limited to punitive damages, arising out of participation in the Physical Activities, including but not limited to the Personal Training/Nutritional Program and the Physical Activities, even if caused by the negligence, intentional acts or omissions and/or any other type of fault of NFS Natural Fitness Systems, LLC, it’s owners, employees or other authorized agents including Independent Contractors.
Client Signature: X______________________________________ Date: _________________
Medical Clearance Form
Dear Doctor:
Your patient _____________________________________________ wishes to take part in an exercise program and/or fitness assessment. The exercise program may include progressive resistance training, flexibility exercises, and a cardiovascular program; increasing in duration and intensity over time. The fitness assessment may include a sub-maximal cardiovascular fitness test and measurements of body composition, flexibility, and muscular strength and endurance.
After completing a readiness questionnaire and discussing their medical condition(s) we agreed to seek your advice in setting limitations to their program. By completing this form, you are not assuming any responsibility for our exercise and assessment program. Please identify any recommendations or restrictions for your patient's fitness program below (Physician's Recommendations).
Patient's Consent and Authorization I consent to and authorize __________________________________________ to release to NFS Natural Fitness Systems LLC., health information concerning my ability to participate in an exercise program and/or fitness assessment. I understand this consent is revocable except to the extent action has already been taken. Authorization is not valid beyond one year from date of signature. Further disclosure or release of my health information is prohibited without specific written consent of person to whom it pertains.
Client’s signature ___________________________________________ Date ___________
Parent signature if minor
Physician's Recommendations I am not aware of any contraindications toward participation in a fitness program.
I believe the applicant can participate, but urge caution because:
The applicant should not engage in the following activities:
I recommend the applicant not participate in the above fitness program.
Physician’s signature _______________________________________________Date _______________
Physician’s name (print)____________________________________________ Phone ______________
Address _______________________________________City ________________Zip ______________