Health & Lifestyle Questionnaire Full Name(required) Phone Number(required) E-mail(required) Home Address(required) Occupation(required) Current Age(required) Date of Birth(required) Gender(required) Male Female Emergency Contact - Name(required) Emergency Contact - Number(required) Emergency Contact - Relationship(required) Physician's Name(required) Physician's Phone Number(required) Physician's Address(required) Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?(required) YES NO Do you frequently have pains in your chest when you perform physical activity?(required) YES NO Have you had chest pain when you were not doing physical activity?(required) YES NO Do you lose your balance due to dizziness or do you ever lose consciousness?(required) YES NO 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.)?(required) YES NO Are you pregnant now or have given birth within the last 6 months?(required) YES NO Have you had a recent surgery?(required) YES NO 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?(required) YES NO If you have marked YES to the above question, please list all medications and what they are for below: How does this medication affect your ability to exercise or achieve your health and wellness goals? Do you smoke?(required) YES NO If yes, how many per day? 1 2 3 4 5 6+ Do you drink alcohol?(required) YES NO If yes, how many drinks per week? 1 2 3 4 5 6+ How many hours do you regularly sleep at night?(required) 1 2 3 4 5 6 7 8 9+ Describe your job(required) Sedentary Active Physically Demanding Does your job require you to travel?(required) YES NO On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?(required) 1 2 3 4 5 6 7 8 9 10 List your 3 biggest sources of stress(required) Do you regularly utilize the services of a massage therapist?(required) YES NO Is anyone in your family overweight(required) YES NO If yes, who? Were you overweight as a child?(required) YES NO If yes, at what age(s) What age were you in the best shape of your life?(required) 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71+ What activities were you partaking in then?(required) Have you been exercising consistently for the past 3 months?(required) YES NO When did you first start thinking about getting in shape?(required) What (if anything) stopped you in the past?(required) On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?(required) 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?(required) 1 2 3 4 5 6 7 8 9 10 How many times a day do you usually eat (including snacks)?(required) 1 2 3 4 5 6 7 8 9+ Do you skip meals?(required) YES NO Do you eat breakfast?(required) YES NO Do you eat late at night?(required) Often Sometimes Rarely Never What activities do you engage in while eating? (TV, reading etc)(required) How many glasses of water do you consume daily?(required) 1 2 3 4 5 6 7 8 9 10+ Do you feel drops in your energy levels throughout the day?(required) YES NO If yes, when? Do you know how many calories you eat per day?(required) YES NO If yes, how many? Are you currently or have you ever taken a multivitamin or any other food supplements?(required) YES NO If yes, please list the supplements At work or school, do you usually(required) Eat out Bring food How many times per week do you eat out?(required) 1 2 3 4 5 6 7+ Do you do your own grocery shopping?(required) YES NO Do you do your own cooking?(required) YES NO Besides hunger, what other reason(s) do you eat (i.e. boredom, social, stressed, tired, depressed, happy, nervous, etc.)?(required) Do you eat past the point of fullness?(required) Often Sometimes Rarely Never Do you consume foods and drinks high in sugar (real & artificial) (i.e. desserts, soda (diet too), juices,)?(required) Often Sometimes Rarely Never List 3 areas of your Nutrition you would like to improve(required) Would you like nutritional education or assistance from a professional coach?(required) YES NO How often do you take part in physical exercise?(required) 5-7x/week 3-4x/week 1-2x/week If your participation is lower than you would like it to be, what are the reasons?(required) Lack of Interest Illness/Injury Lack of Time Other For how long have you been consistently physically active?(required) Do you do Cardio &/or Sports regularly?(required) YES NO What type of cardio &/or Sports? Frequency/Week 1 2 3 4 5 6 7 Average Length 20 MINUTES 40 MINUTES MORE THAT AN HOUR At what Intensity? EASY MODERATE HARD Is cardio conditioning an area that you would like us to help you with?(required) YES NO Do you do Strength Training regularly?(required) YES NO What type of Strength Training? Frequency/Week 1 2 3 4 5 6 7 Average Length 20 MINUTES 40 MINUTES MORE THAT AN HOUR At what Intensity? EASY MODERATE HARD Would you like some assistance with your muscle conditioning program(required) YES NO Do you stretch (either through yoga or by yourself) regularly?(required) YES NO What type of stretching? Frequency/Week 1 2 3 4 5 6 7 Average Length 20 MINUTES 40 MINUTES MORE THAT AN HOUR Would you appreciate some help with a stretching program?(required) YES NO How do you prefer to exercise(required) LARGE GROUPS SMALL GROUPS WITH A TRAINER ALONE COMBINATION When do you prefer to exercise?(required) MORNING AFTERNOON EVENING Realistically, how often a week would you like to exercise?(required) 1x/week 2x/week 3x/week 4x/week 5x/week 6x/week 7x/week Realistically, how much time would you like to spend during each exercise session?(required) Based on your schedule and facility location, where will most workouts take place?(required) BodyFitLA Private Training Gym Home Another Gym Outside Work Gym Based on your commitment, how often would you like to see a trainer to help you achieve your goals?(required) 5x/week 4x/week 3x/week 2x/week 1x/week 1x/two weeks 1x/month Other What are the best days during the week for you to commit to your exercise program?(required) 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.(required) How can a Personal Trainer help you? Please list that which applies. (Develop Muscle Tone, Rehabilitate an Injury, Increase Muscle Size, Safety, Lose Body Fat, Nutrition, Education, Motivation, Fun, Design a more advanced program, Start an Exercise Program, Sports Specific Training, Other)(required) 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 (simple, sensible, significant) M = Measurable (meaningful, motivating) A = Achievable (agreed, attainable) R = Realistic (reasonable, realistic and resourced, results-based) T = Time Bound (time based, time limited, time/cost limited, timely, time-sensitive). Please list in order of priority, the top 3 fitness goals you would like to achieve in the next 3-12 months?(required) How important is it for you to achieve these goals?(required) Very Semi Not Very How long have you been thinking about achieving these goals?(required) How will you feel once you’ve achieved these goals? Be specific.(required) Where do you rate health in your life?(required) Low Priority Medium Priority High Priority How committed are you to achieving your fitness goals?(required) Very Semi Not Very What do you think the most important thing your Personal Trainer can do to help you achieve your fitness goals?(required) 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.).(required) Outline 3 methods that you plan to use to overcome these obstacles:(required) How did you hear about us? Please list all that apply. (Business Card, Referral, Google, Yelp, Word of Mouth, Facebook, Twitter, Instagram, Other)(required) If you were referred to us, who told you about our services? Why did you choose to train with BodyFitLA instead of another organization? Please list all that which applies. (Personal Trainers, Location, Word of Mouth, Cost, Customer Service, Programs, Other)(required) How far do you live from our main training studio? (11116 Weddingston St., North Hollywood, CA 91601)(required) The Gift of Fitness: At BodyFitLA, 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 name and number 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.