New Client Questionnaire

First Name

Last Name

Telephone

Age

Sex

Address

City

State

Zip Code

Birth Date

Emergency Contact

Place Of Employment

Par-Q Exam: Please Mark YES or NO to the following:

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

Yes No

Do you frequently have pains in your chest when you perform physical activity?

Yes No

Have you had chest pain when you were not doing physical activity?

Yes No

Do you lose your balance due to dizziness or do you ever lose consciousness?

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.)?

Yes No

Are you pregnant now or have given birth within the last 6 months?

Yes No

Have you had a recent surgery?

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? Yes/No What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

Lifestyle Related Questions: Answer the Following YES or NO

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

How many hours do you regularly sleep per night?

Describe your job:

Sedentary Active Physically Demanding

Does your job require traveling?

Yes No

On a scale of 1-10, how would you rate your stress level on a normal work day?

Is anyone in your family overweight?

Mother Father Sibling Grandparent

Were you overweight as a child?

Yes No

Fitness History: Fill in below to the best of your knowledge:

When were you in the best shape of your life?

Have you been exercising consistently for the past 3 months?

Yes No

When did you first start thinking about getting into shape?

What worked for you in the past?

What stopped you from reaching your goals in the past?

On a scale of 1-10 how would you rate your current fitness skill/experience level?

Nutrition Related Questions: Answer the questions to the best of your knowledge:

On a scale of 1-10, how would you rate your nutrition?

How many times a day do you usually eat?

Do you eat late at night?

Yes No

How many oz of water do you drink per day?

Do you feel energy highs and lows throughout the day?

Yes No

Do you know how many calories you eat on a regular day?

Are you currently or have you ever taken a multivitamin or any other food supplements?

At work do you eat out or do you meal prep?

Eat out Meal Prep

Do you eat past the point of fullness?

Yes No

How much weight do you want to lose?

Fitness Related Questions:

How often do you workout?

1-2x per week 3-5x per week 6-7x per week

If you can't workout what are the reasons?

Lack of time Lack of energy Zero motivation Need to learn what to do

Do you have a gym?

Home gym Apartment Gym

Will we need to bring equipment?

Yes No

What type of workouts are you most interested in?

High Intensity Interval Training Strength Training Body Building

What's your ideal time to workout

Goal Setting: Tell us about your ultimate goal.

List the top 3 goals you have right now

How long have you thought about these goals?

Where do you rate your goals right now?

Low priority Medium priority High priority

What is the most important thing for us to know about keeping you motivated and on track?

Tell us what keeps you from reaching your goals

What are 3 methods you plan to use to overcome these obstacles

Final Questions

Signature Initials: I have read and understand the following terms: Fill in below with your initials.

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 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 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 understand that At Home 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. Credit cards, cash, and checks made payable to Progress Fitness are all accepted. I understand that all Personal Training sessions are non-refundable.

I understand that At Home Fitness operates on a scheduled appointment basis for all Private Training sessions and thus, requires that I provide 24 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given. Should I cancel a session without 24 hours prior notice, I will be charged in full for that session. I understand that Progress Fitness recommends that all cancelled sessions be rescheduled to ensure consistency and fitness progress.

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 understand that At Home Fitness photographs many of their client events/sessions and I provide written approval for them to use these pictures for promotional purposes.

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