1. Health and Wellness Pre-Screening Questionnaire

New Client Information* This field is required.Please enter your first and last name, email address, and best phone number to reach you.

First Name

Last Name

Email Address

Phone Number

Height

Weight (in pounds)

Date of Birth

Have you ever been treated for, diagnosed as having, or currently experiencing any of the following:* This field is required.

Diabetes

High Cholesterol

Skin tumors, skin cancer or melanoma

Cancer

Any infectious progressive illness, such as Hepatitis B, Acquired Immune Deficiency

Syndrome or other conditions

Physical Therapy

Any circulatory disorder

Neuromuscular/neurological disorders such as seizures

Fainting, convulsions, recurrent headaches, dizziness

Stroke

Nervous or mental disorder

Active rheumatoid arthritis

Osteoporosis

Anti-coagulant medication

Anti-depressive medication

Hormonal treatment / Therapy

Liposuction or cosmetic surgery within the last six months

Allergies

Digestive problems

Laxatives or Diuretics

Smoking

Pregnancy

None / Not applicable

Other

Are you currently taking any medications / drugs that may interfere with your ability to perform rigorous exercise?* This field is required.

YESNO

Have you ever had heart trouble or coronary disease?* This field is required.

YESNO

Has your doctor / cardiologist cleared you for exercise?

YESNO

Please list any injuries and/or surgeries within the last 3 years that may interfere with your ability to perform rigorous exercise:

Please select the date of your most recent physical:* This field is required.

Date

How many hours of sleep do you average per night?* This field is required.Please select from the list below:

How many cups of water do you drink per day?* This field is required.

How many cups of caffeinated beverages do you drink per day?* This field is required.(Soda, coffee, tea, etc.)

Have you ever participated in a diet and/or nutrition program or worked out consistently?* This field is required.

YESNO

Did you achieve your goal(s)?* This field is required.

YESNO

Did you maintain your goal(s)?* This field is required.

YESNO

Have you ever had a personal trainer before?* This field is required.

YESNO

What did you like most about working with them?* This field is required.

What did you like least about working with them?* This field is required.

Have you ever had a bad experience with a physical activity? If yes, please explain:* This field is required.

Are you currently exercising regularly (at least 3x per week)?* This field is required.

YESNO

Please rate your exercise intensity level on a scale of 1 – 5:* This field is required.(How hard do you push yourself during workouts. 1 minimal intensity to 5 the most intense)

1 - I don't break a sweat (on purpose)

2 - Jogging while reading my favorite book

3 - Yoga + Zumba (but only on the weekends)

4 - No pain. No gain.

5 - Hulk out (no roids tho)

Rate yourself on the following scales: * This field is required.

Please rate your readiness for change:* This field is required.

I need change, now.

I'm ready, but hesitant.

I'm somewhat ready.

I'm not at all ready.

Please rate the following goals from 1 (least important) to 5 (most important):* This field is required.

Timeline for achieving your goal:* This field is required.

6 Weeks

12 Weeks

18 Weeks

24 Weeks

30 Weeks

1 Year or more

How many times are you willing to train per week?* This field is required.

At what times during the day would you prefer to train?* This field is required.

Crack of Dawn (before sun up)

Normal Waking Hours (8am - 10am)

College Kid (11am - 1pm)

Hangover Hours (2pm - 4pm)

Dinner Time (5pm - 7pm)

Kids Bedtime (8pm - 10pm)

Please list any equipment you own:* This field is required.