CLIENT INFORMATION QUESTIONNAIRE

 

Please complete and return to your Personal Trainer or to the reception desk at least 2 days prior to your first scheduled session.

 

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and is safe and effective.

 

 

Name:_____________________________ Date of Birth____/____/____ Age:______

                                                                                                M       D       Y

Address:______________________________________________________________

                        Street                                       City                 State                Zip Code

Phone: __________________(h) __________________(o) _________________(fax)

 

Email address: _______________________________________________________

 

Occupation:_____________________________________

 

Emergency Contact: _______________________ Relationship: ________________

 

Phone Number:________________________

 

Physician’s Name:_______________________ Physician’s Phone:_______________

 

Physician’s Address:____________________________________________________

                                    Street                           City                  State                Zip Code

 

Bold Training will send information regarding your physical exercise program to your physician unless you request otherwise.

 

Please provide 48 hours notice if you need to cancel or reschedule your Personal Training appointment.

 

 

 

 

 

 

 

 

       
   
 
 
 
 

www.boldtrainingonline.com l Karen@boldtrainingonline.com

 

 

 
 

 


For office use only: DE  _____     NCL  _____     PL  _____ EE  _____

 

Personal Trainer: __________________________

 

1st Appointment: ___________________________

  

 

PAR-Q FORM     Please mark YES or No to the following:                 YES     NO

 

Has your doctor ever said that you have a heart condition and recommended

only medically supervised physical activity?                                                       ____     ____

 

Do you frequently have pains in your chest when you perform physical activity?  ____     ____

 

Have you had chest pain when you were not doing physical activity?                   ____     ____

 

Do you lose your balance due to dizziness or do you ever lose consciousness?  ____     ____

 

Do you have a bone, joint or any other health problem that causes you pain or

limitations that must be addressed when developing an exercise program

(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis,

anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?  ____    ____

 

Are you pregnant now or have given birth within the last 6 months?                      ____     ____

 

Have you had a recent surgery?                                                                         ____     ____

 

If you have marked YES to any of the above, please elaborate below:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Do you take any medications, either prescription or non-prescription, on a regular basis? Yes/No

 

What is the medication for?_______________________________________________________

 

How does this medication affect your ability to exercise or achieve your fitness goals? ____________________________________________________________________________________________________________________________________________________________

 

Lifestyle Related Questions:

 

1) Do you smoke?                     YES     NO       If yes, how many?__________

 

2) Do you drink alcohol?            YES     NO       If yes, how many glasses per week?__________

 

3) How many hours do you regularly sleep at night?        ___________

 

4) Describe your job: m Sedentary     m Active     m Physically Demanding

 

5) Does your job require travel? YES   NO

 

6) On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)? ______

 

7) List your 3 biggest sources of stress:           

a. _______________________ b. _______________________ c._______________________

 

8) Do you regularly utilize the services of a massage therapist? YES   NO

 

9) Is anyone in your family overweight? m Mother     m Father     m Sibling     m Grandparent

 

10) Were you overweight as a child?       YES   NO          If yes, at what age(s)?______________

Fitness History:

1) When were you in the best shape of your life? _____________________________________

 

2) Have you been exercising consistently for the past 3 months? YES   NO

 

3) When did you first start thinking about getting in shape? _____________________________

 

4) What if anything stopped you in the past? _________________________________________

 

5) On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?_____

 

Nutrition Related Questions

 

1) On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)? _______

 

2) How many times a day do you usually eat (including snacks)? _______________

 

3) Do you skip meals?   YES     NO             4) Do you eat breakfast?     YES     NO

 

5) Do you eat late at night?        m Sometimes     m Often     m Never

 

6) What activities do you engage in while eating? (TV, reading etc) ______________________

 

7) How many glasses of water do you consume daily? _____________

 

8) Do you feel drops in your energy levels throughout the day? YES NO   If yes, when?______

 

9) Do you know how many calories you eat per day?      YES   NO     If yes, how many?_____

 

10)  Are you currently or have you ever taken a multivitamin or any other food supplements? Y N

If yes, please list the supplements: ______________________________________________________________________________________________________________________________________________________

 

11)  At work or school, do you usually: m Eat out m Bring food

 

12)  How many times per week do you eat out? _____________

 

13) Do you do your own grocery shopping? YES     NO

 

14) Do you do your own cooking?          YES          NO

 

15)  Besides hunger, what other reason(s) do you eat?

 

m Boredom     m Social     m Stressed   m Tired     m Depressed     m Happy     m Nervous

 

16) Do you eat past the point of fullness? m Often     m Sometimes   m Never

 

17) Do you eat foods high in fat and sugar? m Often     m Sometimes   m Never

 

18) List 3 areas of your Nutrition you would like to improve:       

 

a.________________________ b.________________________ c.________________________

 

 

 

 

 

 

Exercise Related Questions: Skip to next section if you are presently inactive.

 

1) How often do you take part in physical exercise?

           

                                    5-7x/week          3-4x/week          1-2x/week         

 

2) If your participation is lower than you would like it to be, what are the reasons?

           

            Lack of InterestIllness/Injury      Lack of Time     Other_______________________

 

3) How long have you been consistently physically active for? ______________

 

4) What activities are you presently involved in?

 

            Cardio &/or Sports       Frequency/Week            Average Length             Easy/Mod/Hard

_____________________________________________________________________________________________________________________________________________________________________________________________________________________

 

            Strength Training         Frequency/Week            Average Length             Easy/Mod/Hard

            _______________________________________________________________________

           

            List exercises:____________________________________________________________

            _______________________________________________________________________

           

            Stretching                    Frequency/Week            Average Length            

            _______________________________________________________________________       

 

5)     Please circle all the activities that interest you:

Group Fitness Classes

Indoor Cycling

Snowshoeing

Baseball

Kayaking

Soccer

Basketball

Partner Training

Swimming

Boxing

Pilates

Tennis

Cross Country Skiing

Private Personal Training

Triathlon

Football

Racquetball

Volleyball

Golf

Rockclimbing

Walking

Group Personal Training

Running

Wallyball

Hiking

Skiing

White Water Rafting

Ice Skating      

Snowboarding

Yoga

 

Developing your Fitness Program:

 

1. Please circle how you prefer to exercise:                  

 

a)         INSIDE             OUTSIDE          COMBINATION

 

b)        LARGE GROUPS          SMALL GROUPS          ALONE             COMBINATION

 

c)        MORNING     AFTERNOON     EVENING

 

2. Realistically, how often a week would you like to exercise?     ________x/week

 

3. Realistically, how much time would you like to spend during each exercise session? _______

 

4. What are the best days during the week for you to commit to your exercise program?

 

                        M         T          W         T          F          S          S


5. If you could design your own exercise program, what would an ideal training week look like to you? Please be specific. List your favorite activities, rest days, time spent etc.

 

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Goal Setting:

 

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

 

m Lose Body Fat     m Develop Muscle Tone     m Rehabilitate an Injury     m Nutrition Education m Start an Exercise Program     m Design a more advanced program     m Safety

m Sports Specific Training     m Increase Muscle Size     m Fun     m Motivation

Other______________________________

 

In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure all your goals are ‘SMART’.

 

S= Specific (Provide details, how long, how much etc.)

M= Measurable (How will you measure whether you’ve reached your goals)

A= Attainable (Be realistic, set smaller goals)

R = Rewards-Based (Attach a reward to each goal)

T = Time Frame (Set specific dates for goals)

 

1. Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months?

           

            a)__________________________________________________________________

           

            b)__________________________________________________________________

           

            c)__________________________________________________________________

 

 

  1. How will you feel once you’ve achieved these goals? Be specific.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  1. Where do you rate health in your life? m Low priority   m Medium Priority   m High priority

 

4. How committed are you to achieving your fitness goals? m Very   m Semi   m Not very

 

5. What do you think the most important thing your Personal Trainer can do to help you achieve your fitness goals?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

6. Outline what you feel are the obstacles or your potential actions, behaviors 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.________________________

 

Miscellaneous Questions:

 

1. How did you hear about us? Please check that which applies.

 

m Brochure m Yellow Pages m Website   m Drop-in

m Word of Mouth Referral – Who?_________________________________________________

m Newspaper/Magazine Column – Which one? _______________________________________

m Flier in local business – Where? _________________________________________________

m Chamber of Commerce m Other_________________________________________________

 

3. Why did you choose to train with Bold Training instead of another organization? Please check that which applies.

 

m Location m Personal Trainers m Cost m Customer Service m Word of Mouth

m Programs m Other_____________________________   

 

4. How far do you live from our training studio? _______miles

 

5. Which newspaper(s) do you read? _____________________________________

 

6. Which radio station(s) do you listen to? ________________________________

 

7. Which local magazine(s) do you read? _________________________________

 

8. Which local morning TV show do you watch? ___________________________

 

9. What would cause you to discontinue training with Northwest Personal Training? _____________________________________________________________________

 

10. The Gift of Fitness:

 

At BoldTraining we rely on happy clients telling others about our services. We may both be able to make a huge difference in somebody's life. Please take the time to jot down the names of 2 friends who you would like to offer a complimentary consultation to. Once you discuss this with them, we'll call them and book them for their first session.    

           

Name                                                                            Phone

i.___________________________________         __________________________

 

ii.___________________________________        __________________________


PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT

 

1)            I, ____________________________________________, wish to participate in the exercise and training program offered by Bold Training . I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program.   I agree that Bold Training shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Bold Training , its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and assigns.

 

            I have read and understand this term: ________(initial)

 

2)            I certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform all employees of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.

           

            I have read and understand this term:________(initial)

 

3)            I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer, Group Fitness Instructor or alternate staff.

 

            I have read and understand this term:________(initial)

 

4)            I understand the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.

 

            I have read and understand this term:________(initial)

 

5)            I understand that all Private Personal Training rates are based on 25, 55 or 85 minute sessions and should I arrive late, there is no guarantee I will receive the full session with my trainer. In return, if my Personal Trainer is late for a session, I will still receive the full session time.

 

            I have read and understand this term:________(initial)

 

6)            I understand that Bold Training bills its Personal Training clients on a pre-pay basis. Once my trainer and I have decided upon the type of training package and payment plan I will purchase, payment must be made before the sessions are conducted. Credit cards, cash and checks made payable to Bold Training are all accepted. I understand that all Personal Training sessions are non-transferable and non-refundable. I also understand that all Private Personal Training sessions must be redeemed within one year of purchase.

 

            I have read and understand this term:________(initial)

 

7)            I understand that Bold Training operates on a scheduled appointment basis for all Private Training sessions and thus, requires that I provide 48 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 48 hours notice given. Should I cancel a session with 48-24 hours prior notice, I will be charged 50% for that session. Should I cancel a session with LESS than 24 hours prior notice, I will be charged in full for that session and work will be completed on my program in my absence. I understand that Bold Training recommends that all cancelled sessions be rescheduled to ensure consistency and fitness progress.

 

            I have read and understand this term:________(initial)

 

8)            I understand that during a personal training or group training session, my trainer/instructor may have to use Touch Training to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch Training, I will immediately request that it be discontinued.

 

            I have read and understand this term:________(initial)

 

9)            I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by my Personal Trainer or any other staff member.

 

I have read and understand this term:________(initial)

 

10)         I understand that should my Personal Trainer become ill or is away on holidays, another trainer will be assigned to me so that my fitness progress does not suffer. I also understand that in the event that my Personal Trainer is no longer employed by Bold Training, a suitable Personal Trainer will be re-assigned to oversee my program and workout sessions.

 

I have read and understand this term:________(initial)

 

11)         I understand that Bold Training photographs many of their client events/sessions and I provide written approval for them to use these pictures for promotional purposes.

 

           I have read and understand this term:________(initial)

 

I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.

 

______________________________         ______________________________

CLIENT                                                              PERSONAL TRAINER

_____________________                              _____________________

DATE                                                               DATE

 

ADDRESS:

   1908 NW 1st Way

   Suite 101

   Battle Ground, Wa 98604

 

PHONE: (360) 687-2230

 

 HOURS:

   MONDAY - FRIDAY:  6am - 7pm

   SATURDAY: Appointment Only

   SUNDAY:  Closed

 

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