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Fitness

Hi, there!

Please complete this form prior to our initial meeting. Expect to spend about 20-30 minutes with it. Provide as much information as you can for the foundation of your program.

First Name

Last Name

Email

Birthday

Phone

Address

Height

Starting Weight

Initial Measurements

If you do not have a measuring tape at home, it is recommended that you purchase one. Please record landmarks, such as moles, birthmarks, tattoos, or distance from a joint (ex. leg measurement is 10 inches up from the top of the knee cap, arm measurement is 4 inches above the point of the elbow, etc.), in order to record accurate progress measurements.

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Initial Progress Photos
Dress up or down as much as you are comfortable. Keep in mind that the more of your body that I can see, the more changes I will be able to observe. Suggested attire for progress photos: a bathing suit, sports bra + compression shorts (women), compression shorts, etc. If you choose to wear a shirt/shorts, it is encouraged to wear closely fitting and light colored clothing (it probably wont be terribly flattering, but it will make it easier to observe progress). Keep track of your progress photo outfit. It is best to take all progress photos in the same attire. Please provide a separate photo for the FRONT, BACK, LEFT SIDE, and RIGHT SIDE.

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About Your Work
This section will help me to understand the kind of stress you are managing and what your typical daily activity is like.

What do you do for work?

What do you like about your job? What do you dislike?

How much break time do you have during a typical workday?

How much time do you spend on your feet during a typical workday?

0-2 hours

2-5 hours

5-8 hours

8+ hours

How much time do you spend sitting during a typical workday?

0-2 hours

2-5 hours

5-8 hours

8+ hours

How much stress do you deal with at work?

None

Light

Moderate

Extreme

What kind of stress do you deal with at work?

What mechanisms do you employ for stress management?

Do you take work home with you?

Tell me about YOU:)
This section helps me to understand who YOU are better and how to build the best experience I can for you.

What are your hobbies?

How much time each week do you commit to focusing on your hobbies?

0-2 hours

2-5 hours

5-8 hours

8+ hours

What are you proud of? What do you love about yourself?

What is your favorite holiday?

What is your favorite color?

What is your favorite animal?

What is your favorite TV show, movie, and/or book?

What kind of music do you enjoy?

How many people are in your family?

Do you have kids?

Yes

No

How many?

What makes you excited about life?

Exercise History
This section helps me to program something that you will enjoy while supporting your fitness goals.

What motivated you to work with a personal trainer? Why do you want to improve your health and fitness?

Describe your primary goal while working with me:

Have you worked previously with a personal trainer or had nutrition guidance? What worked or did not work with them?

What do you expect from working with a personal trainer?

Please describe your current exercise routine/program, if you are following one. What do you like/dislike about it?:

What types of physical activity do you enjoy outside of the gym?

How many hours/week do you participate in physical activity?

None

0-1 hour

1-3 hours

3-5 hours

5+ hours

How many days/week do you participate in physical activity?

Describe the intensity of your routine physical activity:

Mild

Moderate

Intense

Very Intense

How long is a typical exercise session for you?

15-30 minutes

30-45 minutes

60-90 minutes

2 hours

> 2 hours

What are your perceived weaknesses in achieving your health and fitness goals?

Describe when you felt the healthiest/most happy with your health and fitness:

Nutrition History
This section will help me to know what nutrition preferences, limitations, and habits you may have to build the best long-term, balanced and sustainable nutrition approach to for you.

Describe your food intake during a typical weekday:

Describe your food intake during a typical weekend day:

Describe your food intake at social events/gatherings:

How many meals + snacks do you eat daily?

Describe any allergies or other medically supported dietary restrictions you are aware of:

List your 3 favorite breakfast meals:

List your 3 favorite snacks:

List your 3 favorite dinner meals:

List your 3 favorite meals when eating out and/or favorite restaurants:

List your 3 favorite desserts:

List your 3 favorite carb sources:

List your 3 favorite meats:

List any supplements you are taking (including protein powder):

List any foods that you do not like/will not eat:

How many oz of water do you drink daily?

What else do you drink during the day? How much?:

How familiar are you with MyFitnessPal?

Never heard of it

Never used, but have heard of it

Very brief use

Intermittent use

Regular use

HealthHistory

Do you smoke cigarettes?

Yes

No

How many do you smoke daily?

Do you drink alcohol?

Yes

No

How often and how much do you drink?

Select any of the following that are true for you:

Family or personal health history of heart disease

Family or personal health history of diabetes

Family or personal health history of respiratory disease (asthma, etc)

Any bone or joint problems

Any medical conditions that may limit your ability to participate in physical activity

Recent surgeries (in the past 6 months)

Please provide a description for any of the selections made:

Please describe any current medications you may be taking:

By checking this box, you agree to and accept responsibility to consult with your physician and communicate to your trainer any relevant concerns expressed by your physician regarding an increase in physical activity.

Thanks for submitting!
I will get back to you shortly.

© 2015 by Train With Cecily LLC

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