Part 1: Basic Info & Health Assessment
Your information will never be shared because privacy matters!
Full Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
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Weight
*
Height
*
Occupation
*
What do you do for a living?
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What is your ideal exercise time (ie. early mornings, late afternoons, etc.)
*
How did you hear about us?
*
Choose the programs you're interested in (you can make multiple selections)
*
Weight Loss
Strength Training
Personal Training for Women
Body Recomp (getting leaner and more muscular)
Athletic Improvement & Fitness Competitions
Nutritional Coaching & Motivation
Accountability
Injury Rehab or Senior Fitness
Other
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Please check all existing conditions
Heart Disease
Pulmonary Disease
Metabolic Disease
Family History of Heart Disease
High Blood Pressure
High Cholesterol
Smoking
Sedentary Lifestyle
Chest Pain
Dizziness
Shortness of Breath
Irregular/Accelerated Heart Rate
Osteoporosis
Arthritis/ Joint Pain
Back Pain/Spine Disorder
Musculoskeletal Pain/ Injury
Hernia
Surgery
Food Allergies
Hypoglycemia
G.I. Disorder
High Triglycerides
Cancer
Pre/Postnatal
Anemia
Other
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Is your physician prescribing medication for a blood pressure or heart condition?
Yes
No
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Are you over 69 and not used to being active?
Yes
No
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Has a physician ever told you that you have a bone or joint problem that will worsen with exercise?
Yes
No
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Do you know of any reason why you should not participate in physical activity?
*
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Part 2: Fitness Readiness
What is your current workout routine like?
*
What is your current workout routine like?
*
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What would your ideal workout routine be like?
*
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What are your fitness goals? What would you like to achieve? And why is it important to you?
*
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What has it been like trying to achieve the goals you listed? What have you tried? What worked or didn't work?
*
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Where do you rate health as a priority in your life?
*
1 - Lowest
2
3
4
5 - Highest
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How committed do you feel about reaching your fitness goals described above?
*
1 - Lowest
2
3
4
5 - Highest
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Where do you get your fitness knowledge from? (mark all that apply)
Magazines
Science Journals (i.e. pubmed indexed studies)
Fitness Blogs/Websites
Social Media
Friends and Family
Fitness Professionals (nutritionists, trainers, group instructors, etc.)
Search Engine Research (google)
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Would you like to test your fitness IQ?
(10 multiple choices questions)
Choose
Yes I would like to take the short Fitness IQ Quiz
No I want to end this interview and submit my information
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One must exercise in order to lose weight (body-fat)
TRUE
FALSE
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Core exercises (i.e. crunches) are necessary for visible abs
TRUE
FALSE
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Nutritionally speaking, you can reduce body-fat by: (mark one or more)
Reducing carbohydrate intake
Reducing calorie intake
Reducing fat intake
Reducing sodium intake
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There really is no such thing as good fats vs. bad fats
TRUE
FALSE
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You can lose weight by reducing calories, even if you eat lots of sugar/carbs
TRUE
FALSE
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Eat smaller frequent meals to make your metabolism faster and thus lose weight faster
TRUE
FALSE
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Juicing and/or Detoxing are great for cleansing your body and losing weight
TRUE
FALSE
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Every exercise program should have a foundation of
Weight lifting
Cardio
Walking
It doesn't matter what you do as long as you get moving
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Lifting weights will not help you become more "toned"
TRUE
FALSE
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You gain muscle mass by (mark one or more):
Consuming adequate protein
Consuming adequate calories
Lifting weights
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E-mail
*
example@example.com
Phone Number (Cell Preferred)
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Congratulations! If you have made it this far then you are most certainly on your way towards achieving any goals that you have set for yourself. Your determination and the correct exercise program will keep you motivated to get into the best shape of your life!
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