CLIENT INFORMATION QUESTIONNAIRE

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 interests and is safe and effective.

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

M D Y

Address:______________________________________________________________

Street City State Zip Code

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

Email address: _______________________________________________________

Occupation:_____________________________________

Emergency Contact: _______________________ Relationship: ________________

Phone Number:________________________

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

Physician’s Address:____________________________________________________

Street City State Zip Code

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

Peak Physique Fitness

206.779.1279

Connie@gettingyoufit.com www.gettingyoufit.com

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) Is anyone in your family overweight? mMother mFather mSibling mGrandparent

9) 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?

mBoredom 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 Interest Illness/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:

Aerobic 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
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)__________________________________________________________________

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

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

3. 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

1. ______________________________________________________________________

2. _____________________________________________________________________

c. ______________________________________________________________________

PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT

1) I, ____________________________________________, wish to participate in the exercise and training program offered by Peak Physique Fitness. 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 Peak Physique Fitness 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 Peak Physique Fitness 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 my Personal Trainer 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.

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 or 55 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 Peak Physique Fitness 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. Cash and checks made payable to Peak Physique Fitness are accepted. I understand that all Personal Training sessions are non-transferable and non-refundable.

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

7) I understand that Peak Physique Fitness is 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. I understand that Peak Physique Fitness 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 session, my trainer 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 my trainer discontinue using this technique.

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.

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

10) I understand that Peak Physique Fitness 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