INFORMATION QUESTIONNAIRE

Please take the time to complete this form as accurately as possible. The information here will be utilized to assist you in maximizing your fitness goals.

FULL NAME

PrefixFirst NameLast NameSuffix

ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

PRIMARY PHONE NUMBER

Area CodePhone Number

CELL PHONE NUMBER

Area CodePhone Number

E-MAIL ADDRESS

DATE OF BIRTH

MonthDayYear

GENDER

WHAT BEST DESCRIBES YOUR OCCUPATION?

IS YOUR JOB OR LIFE:

HOW TALL ARE YOU IN INCHES?

HOW MUCH DO YOU THINK YOU WEIGH?

WHAT DO YOU THINK IS YOUR WAIST CIRCUMFERENCE IN INCHES?

DO YOU SMOKE?

HAVE YOU EVER BEEN DIAGNOSED WITH DIABETES?

MAJOR OBSTACLES TO HEALTHY EATING:

WHERE DO YOU MOST OFTEN EAT BREAKFAST?

WHERE DO YOU MOST OFTEN EAT LUNCH?

WHERE DO YOU MOST OFTEN EAT DINNER?

HOW MANY SERVINGS OF FRUITS, VEGETABLES AND JUICES?

HOW MANY SERVINGS OF ANIMAL BASED PROTEIN (MEAT)?

HOW MANY SERVINGS OF DAIRY OR SOY?

HOW MANY SERVINGS OF CEREALS, BREADS, RICE, OR PASTA?

HOW MANY ARE WHOLE GRAINS, FRUITS OR VEGETABLES?

HOW MANY CUPS OF BEVERAGES THAT CONTAIN CALORIES PER DAY?

DO YOU TYPICALLY EAT BREAKFAST?

DO YOU TYPICALLY EAT LUNCH?

DO YOU TYPICALLY EAT DINNER?

HOW MANY SNACKS DO YOU TYPICALLY EAT PER DAY?

DO YOU TYPICALLY EAT ANYTHING WITHIN 2 HOURS OF GOING TO BED AT NIGHT?

HOW MANY TIMES PER WEEK DO YOU TYPICALLY EAT IN A FAST FOOD RESTAURANT?

ARE YOU A VEGETARIAN?

DO YOU TAKE SUPPLEMENTS?

HOW MANY TIMES DO YOU EXERCISE FOR 20 MINUTES OR MORE?

COMPARED TO PEOPLE YOUR AGE, DO YOU CONSIDER YOURSELF ACTIVE?

DO YOU PARTICIPATE IN ANY MODERATE TO HIGH INTENSITY ACTIVITIES [CYCLING, JOGGING, FITNESS CLASS]?

DO YOU PARTICIPATE IN A LOW TO MODERATE INTENSITY ACTIVITY [WALKING, SWIMMING]?

DO YOU PARTICIPATE IN A STRENGTH TRAINING PROGRAM?

DO YOU PERFORM HEAVY HOUSEWORK OR GARDENING?

HAS YOUR DOCTOR EVER SAID THAT YOU HAVE A HEART CONDITION AND SHOULD LIMIT PHYSICAL ACTIVITY?

DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU DO PHYSICAL ACTIVITY?

IN THE PAST MONTH, HAVE YOU HAD CHEST PAIN WHEN NOT DOING PHYSICAL ACTIVITY?

DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS, OR EVER LOSE CONSCIOUSNESS?

DO YOU HAVE BONE OR JOINT PROBLEMS THAT COULD BE MADE WORSE BY A CHANGE IN YOUR PHYSICAL ACTIVITY?

WERE YOU RECENTLY PRESCRIBED DRUGS FOR YOUR BLOOD PRESSURE OR HEART CONDITION?

IS THERE ANY OTHER MEDICAL REASON WHY YOU SHOULD NOT DO PHYSICAL ACTIVITY?

DO YOU HAVE ASTHMA?

DO YOU HAVE BREATHING PROBLEMS WITH EXERCISE OR COUGH AFTER EXERTION AND HAVE NOT BEEN DIAGNOSED WITH ASTHMA?

HAS ANYONE IN YOUR FAMILY DIED OF HEART PROBLEMS OR OF NON-TRAUMATIC DEATH BEFORE THE AGE OF 55?

HAVE YOU BEEN DIAGNOSED WITH OSTEOPOROSIS?

HAVE YOU EVER SUSTAINED A STRESS FRACTURE?

HAVE YOU TAKEN CORTISONE-LIKE DRUGS FOR A PROLONGED PERIOD OF TIME?

ARE YOU HAPPY WITH YOUR CURRENT WEIGHT?

IF NOT, WHAT IS YOUR DESIRED WEIGHT?

DO YOU FEEL YOU ARE AT RISK FOR EATING DISORDERS?

AT WHAT AGE DID YOU HAVE YOUR FIRST PERIOD?

HOW OFTEN DO YOU HAVE YOUR PERIOD?

DO YOU CURRENTLY USE BIRTH CONTROL PILLS?

LIST ANY CURRENT MEDICAL/PHYSICAL ISSUES THAT COULD AFFECT YOUR TRAINING AND INCLUDE THE DATE THEY BEGAN:

SURGERIES AND YEAR (include C-sections if applicable)

SELECT ANY THAT APPLY IN YOUR 10 YEAR MEDICAL HISTORY [All information is strictly confidential.]

DO YOU CONSISTENTLY TAKE ANY OF THE FOLLOWING MEDICATIONS?

LIST ANY MEDICATIONS, VITAMINS, OR SUPPLEMENTS THAT ARE NOT LISTED ABOVE:

THIS INFORMATION IS STRICTLY FOR YOUR SAFETY DURING TRAINING SESSIONS. IT IS NOT SHARED WITH ANYONE OTHER THAN YOUR TRAINING TEAM AND IS KEPT STRICTLY CONFIDENTIAL UNDER HIPA GUIDELINES.

THE FOLLOWING QUESTIONS MUST BE ANSWERED PRIOR TO EXERCISING:

ARE YOU OVER THE AGE OF 18?

ARE YOU ACCUSTOMED TO EXERCISE?

DO YOU CURRENTLY SMOKE?

DO YOU HAVE BONE OR JOINT PROBLEM/PAIN?

PLEASE CHECK ANY THAT APPLY:

OTHER? PLEASE EXPLAIN:

DO YOU OFTEN GET PAINS IN YOUR CHEST?

DO YOU EVER FEEL FAINT/DIZZY?

IF YES, WHEN?

HAVE YOU BEEN DIAGNOSED WITH HEART TROUBLE?

HAVE YOU BEEN DIAGNOSED WITH HIGH BLOOD PRESSURE?

SELECT YOUR TOP 3 FITNESS GOALS:

OTHER? Please describe.

HOW DID YOU HEAR ABOUT US?

If through a friend, please let us know who to thank!

The Undersigned agrees to abide by the rules of Rock Workout; recognizes the risks involved in use of facilities, services and programs, and shall undertake at their sole risk; Rock shall not be liable for any injuries, accidents, or death occurring to guest, arising either directly or indirectly out of utilizing the facilities, services or programs. I recognize that my photo may be inadvertently included in other photographs taken at Rock for advertising purposes and may be used without further consent. Guest and on behalf of executors, administrators, and heirs does hereby expressly release, discharge, waive, relinquish Rock and its officers for any such claims, demands, injuries, damages or cause of action, with respect to use of the facilities, programs and services. The undersigned guest has completed the medical questionnaire as required and declares to be physically able to participate in activity. Furthermore, guest declares that Rock Workout has advised guest to obtain medical clearance in the event he/she answers yes to any of the medical history questions, or if he/she is unsure of his/her physical health and that guest maintains being capable of pursuing physical activity without such steps being taken, or has done so.

FULL NAME

First NameLast Name

I AM COMPLETING THIS FORM ONLINE AND HAVE CHOSEN "YES" TO INDICATE I AGREE TO THE ABOVE AND HAVE ENTERED MY FULL NAME ABOVE:

TODAY'S DATE

MonthDayYear

EMERGENCY CONTACT:

First NameLast Name

PHONE NUMBER

Area CodePhone Number

ALTERNATE CONTACT:

First NameLast Name

PHONE NUMBER

Area CodePhone Number

If you wish to NOT be included in the following, please select:

NEW CLIENT QUESTIONNAIRE

PERSONAL INFO

EATING AND NUTRITIONAL NEEDS

DESCRIBE A TYPICAL DAY'S NUTRITION

CURRENT EXERCISE HABITS

MEDICAL INFORMATION - PRE-PARTICIPATION:

OSTEOPOROSIS & OSTEOPENIA

FOR WOMEN ONLY:

GUEST AGREEMENT/WAIVER