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CLIENT INFORMATION QUESTIONNAIRE

Please complete and return to us at least 2 days prior to your first scheduled session.

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.

*	First Name:
*	Last Name:
*	Address:
	Address 2:
*	City:
*	State:
*	Zip:
*	Email Address:
*	Phone:
*	Date of Birth
	Occupation
	Emergency Contact
	Relationship
	Phone Number
PAR-Q Form 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?	YesNo
*	Do you frequently have pains in your chest when you perform physical activity?	YesNo
*	Have you had chest pain when you were not doing physical activity?	YesNo
*	Do you lose your balance due to dizziness or do you ever lose consciousness?	YesNo
*	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.)?	YesNo
*	Are you pregnant now or have given birth within the last 6 months?	YesNo
*	Have you had a recent surgery?	YesNo
	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?	YesNo
	If Yes, what is the medication for?
	How does this medication affect your ability to exercise or achieve your fitness goals?
Lifestyle Related Questions
*	Do you smoke?	YesNo
	If "Yes", how many?
*	Do you drink alcohol?	YesNo
	If "Yes", how many glasses per week?
*	How many hours do you regularly sleep at night?
*	Describe your job:	--SedentaryActivePhysically Demanding
*	Does your job require travel?	YesNo
*	On a scale of 1-10, how would you rate your stress level? Please enter a value between 1 and 10. (1=very low 10=very high)
*	List your 3 biggest sources of stress
	Is anyone in your family overweight?	Mother Father Sibling Grandparent
	Were you overweight as a child?	YesNo
	If "yes", at what age(s)?
Fitness History
*	When were you in the best shape of your life?
*	Have you been exercising consistently for the past 3 months?	YesNo
*	When did you first start thinking about getting in shape?
	What if anything stopped you in the past?
*	On a scale of 1-10, how would you rate your present fitness level? Please enter a value between 1 and 10. (1=Worst 10=Best)
Nutrition Related Questions
	On a scale of 1-10, how would you rate your Nutrition? Please enter a value between 1 and 10. (1=very poor 10=excellent)
*	How many times a day do you usually eat (including snacks)?
*	Do you skip meals?	YesNo
*	Do you eat breakfast?	YesNo
*	Do you eat late at night?	SometimesOftenNever
	What activities do you engage in while eating? (TV, reading etc)
*	How many glasses of water do you consume daily?
*	Are you currently or have you ever taken a multivitamin or any other food supplements?	YesNo
*	List 3 areas of your nutrition you would like to improve:
Exercise Related Questions:
Skip to the next section (Goal Setting) if you are persently inactive.
	How often do you take part in physical exercise?	--5-7 times a week3-4 times a week1-2 times a week
	If your participation is lower than you would like it to be, what are the reasons?	--Lack of InterestIllness/Injury Lack of TimeOther...
	If 'Other', please specify
	How long have you been consistently physically active for?
What activities are you presently involved in?
*	Include Cardio&/orSports, Frequency/Week, Average Length, and Easy/Mod/Hard
*	Include Strength Training, Frequency/Week, Average Length, and Easy/Mod/Hard
Goal Setting
*	How can a Personal Trainer help you? Please check all that apply.	Lose Body Fat Nutrition Education Develop Muscle Tone Rehabilitate an Injury Start an Exercise Program Design a more advanced program Safety Sports Specific Training Increase Muscle Size Fun Motivation
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)
*	Please list in order of priority, the 3 fitness goals you would like to achieve in the next 3-12 months?
*	How will you feel once you've achieved these goals? Be specific.
*	Where do you rate health in your life?	Low PriorityMedium PriorityHigh Priority
*	How committed are you to achieving your fitness goals?	VerySomewhatNot Very
*	What do you think the most important thing your Personal Trainer can do to help you achieve your fitness goals?
	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.).
*	Outline 3 methods that you plan to use to overcome these obstacles.
Miscellaneous Questions
*	How did you hear about us? Please check that which applies.	Brochure Word of Mouth Yellow Pages Website Flyer Door Hanger Newspaper Ad Magazine Ad Direct Mailer Facebook Search Engine
	If you were referred to us, who told you about our services?
	Why did you choose to train with Pulse Fitness instead of another organization? Please check that which applies.	Location Personal Trainers Cost Customer Service Word of Mouth Programs
*	How far do you live from our training studio? (in miles)
*	Which newspaper(s) or local magazines do you read?
	Which radio station(s) do you listen to?
	Which local morning TV show do you watch?
	What would cause you to discontinue training with Pulse Fitness?