MEDICAL / EXERCISE HISTORY & LIFESTYLE QUESTIONNAIRE

Contact Information

Last Name

First Name
   
Home Phone

Mobile Phone

Email
                    

How did you hear about this EVERYBODYFIT boot camp?

Personal / Lifestyle Information

Age    Birth Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Has your body weight fluctuated in the past 1-5 years?  + 5-10 lbs + 10-20 lbs + 20 or more lbs - 5-10 lbs - 10-20 lbs -20 or more lbs Not much fluctuation Other

What was your weight at age 18? lbs

How may hours of sleep do you typically get a night? 2-4 Hours 5-6 Hours 7-8 Hours 8+ Hours

Do you drink alcoholic beverages?  Yes No  If so, which do you consume, and how much of each? (Click all that apply below:)
  Beer (12 oz); 1-3 Beer (12 oz); 4-6 Beer (12 oz); 7+ Wine (6 oz); 1-3 Wine (6 oz); 4-6 Wine (6 oz); 7+ Liquor (1.5 oz); 1-3 Liquor (1.5 oz); 4-6 Liquor (1.5 oz); 7+

Comments:

Exercise History
Are you currently involved in a regular exercise program?  Yes No

How often do you exercise?  (Exercise, for now can be defined as any consistent physical activity, i.e. walking, jogging, lifting weights, or rec sports lasting more than 30 minutes continually at a time.) 
Never Rarely 1 x / week Several x / week Daily

Workout Venue    Fitness Center / Health Club Home Outside (Walk/Run) Other
What fitness center or "other" venue?
                   
What does a typical workout consist of?  (This can be any consistent physical activity you participate in.) Click all that apply, then please comment in the box below to give me an idea of a typical workout:

Tell me about your very last workout (Continue below or tell me more yourself): 
I warmed up with . . . My cardio consisted of . . . For strength, I did . . .

How long did your workout last? 0-30 min 30-60 min 1-1.5 hrs 1.5+ hrs  

Physical Activity Readiness Questionnaire (PAR-Q)
For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Please read and check the yes or no opposite the question.

*If your health changes and answers above are altered, please notify your personal trainer, and we will discuss seeking guidance from a physician.

Personal Medical History

Have you had any surgeries that may have an effect on your exercise performance?  Yes  No
List and briefly describe below:
Surgery, Year, Any post-surgical complications?

Do you have any other aches and pains (i.e. low back) that hinder or may hinder your exercising?  Yes No

Have you ever been diagnosed with, or experienced any of the following? (Click all that apply)

Please tell us about what you hope to get out of this boot camp: (Select all that apply)

Please add any other goal related specifics (in your own words) below:

In a nutshell, what motivates you?  What motivates you to work towards the goals listed above?  What has motivated you in the past?


Please discuss any specific motivators above, and check anything that may apply, included in the list below:

What has happened, if ever in the past, that may have caused you to lose this motivation, or fall off track?
Did not see any results
Got bored
Not enough direction, not really sure what to do or how to progress with exercise
Personal life experience (Career change, had baby, injury, other)
Too busy with work and/or family, (long hours, lots of travel, family obligations)
It just happened, I don't really have that great of an excuse
Anything else? Please explain:

Nutrition
How would you rate your nutritional habits as of today?  10 - Right On Track 9 8 7 - Good during the week? 6 5 - Could be better 4 3 - At least my breakfast is OK 2 1 - Supersize That Please!

Do you normally eat breakfast? Yes No     

What was your breakfast this morning?  Is this typical?

Do you or have you supplemented with any of the following (Check all that apply):

Can you tell us a little bit about the supplments you take, i.e., type of protein, what individual vitamins, what brand fat burner?

How would you describe your "nutritional focus"?
I have no nutritional focus 
Low Fat 
Low Carb 
Everything in moderation
Small portion sizes
Grilled chicken & spinach during the week, wings and beer on the weekend
Other (Explain below):

Do you follow, or have you followed a specific diet?  If so, check the appropriate one and explain below.
South Beach  Atkins  Weight Watchers  Jenny Craig  Zone Diet  40-30-30
Other

Fitness Information
Where do you get most of your health and fitness information?  (Click all that apply.)
Fitness Magazines Internet Newspaper Doctor Other Magazines TV
Book(s) Other

Have you ever ordered a fitness product online? (Book, DVD, Exercise Equipment)

Questions for St. Louis Bridal Boot Campers Only

(*If you are not in the bridal boot camp, click this box, "I am not in the bridal boot camp", scroll down to the bottom, and please submit the form. Thank You.)

(FROM REBECCA:

1. My ability to help you with your wedding plans is exponentially sharpened by knowing your budget and number of guests invited. Please share those with me if you feel comfortable.

2. Please also share who you have hired &/or where you are in the process of hiring your 10-13 vendors.

3. Rank your top three priorities & a brief description for "my perfect wedding day".
1. 2. 3. My perfect wedding day is . . .

4. What, if any, has been the biggest surprise in planning your wedding so far.

*Please bring your wedding planning materials... you'll want to take notes.

*I will prepare a syllabus for you to see what we will be discussing each week so that you may bring pointed questions.

Thank you so much, I look forward to working with you, Rebecca.

Please let us know if you have any other questions or comments.

Thank you for taking the time.  Please click the SUBMIT button only once, it may take a minute to process.