Virtual Training Client Information Questionnaire

Virtual Personal Training - Client Information Questionnaire

All information received will be treated as strictly confidential. Please fill out the form completely and accurately. This information will allow me to design programs that address your needs/goals while considering your safety.

Name*
FirstLast
Date of Birth:*
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone*
Email*
Emergency Contact*
Relationship*
Emergency Contact Telephone*
Physician's Name and Telephone*
PAR-Q FORM
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
- Yes
- No
Do you feel pain 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 you 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
If YES, what is the medication for? Please elaborate below.*
How does this medication affect your ability to exercise or achieve your fitness goals?*
LIFESTYLE RELATED QUESTIONS
Do you smoke?*
- Yes
- No
How many hours do you regularly sleep at night?*
Describe your day to day lifestyle:*
- Sedentary
- Active
- Physically Demanding
On a scale of 1-10, how would you rate your stress level?*
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?*
- Yes
- No
If yes, at what age?*
FITNESS HISTORY
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, if anything, stopped you in the past?*
On a scale of 1-10, how would you rate your present fitness level?*
1 = Worst, 10 = Best
NUTRITION RELATED QUESTIONS
On a scale of 1-10, how would you rate your nutrition?*
1 = Very Poor, 10 = Excellent
How many times a day do you usually eat (including snacks)?*
Do you skip meals?*
- Yes
- No
Do you eat breakfast?*
- Yes
- No
How many glasses of water do you consume daily?*
Do you feel drops in your energy levels througout the day?*
- Yes
- No
If yes, when?*
EXERCISE RELATED QUESTIONS
How often do you take part in physical exercise?*
- 5-7 times per week
- 3-4 times per week
- 1-2 times per week
- I am not presently active
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
If you selected OTHER, please elaborate below:*
For how long have you been consistently physically active?*
What CARDIO/SPORTS activities are you currently involved in? For each entry, please answer the following questions: How many times per week? How long is each session? What is the level of difficulty?*
Level of difficulty: Easy/Moderate/Hard
Is cardio conditioning an area that you would like help with?*
- Yes
- No
What STRENGTH TRAINING activities are you currently involved in? For each entry, please answer the following questions: How many times per week? How long is each session? What is the level of difficulty?*
Would you like some assistance with a muscle conditioning program?*
- Yes
- No
What STRETCHING activities are you currently involved in? For each entry, please answer the following questions: How many times per week? How long is each session? What is the level of difficulty?*
Would you appreciate some help with a stretching program?*
- Yes
- No
DEVELOPING YOUR FITNESS PROGRAM
How would you prefer to exercise?*
- Large Groups
- Small Groups
- Alone
- Combination
- With my Kids
When would you prefer to exercise?*
- Morning
- Afternoon
- Evening
Realistically, how often a week would you like to exercie?*
What are the best days during the week for you to commit to your exercise program?*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Do you own any equipment to use in your workouts? Ie. Treadmill, weights, tubing?*
Where do you plan to do your workouts? Home (which room), outside, gym, etc?*
Do you have access to stairs, hiking trails, hills to include in your exercise program?*
Are there any exercises you love or hate? (ie. love jumping jacks, hate push-ups)*
GOAL SETTING
Please list, in order of priority, the the fitness goals you would like to achieve in the next 3-12 months.*
How important is it for you to achieve these goals?*
- Very Important
- Important
- Not Very Important
How long have you been thinking about achieving these goals?*
How will you feel once you've achieved these goals? Be specific.*
What do you think is the most important thing your Virtual Trainer can do to help you achieve your fitness goals?*
Outline what you feel are the obstacles or your potential actions, behaviours, or activities that could impede your progress towards accomplishing your goals (ie. family responsibilities, crazy schedule, 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 CareerFit Mom?*
- Posters
- Brochure
- Website
- Newspaper/Magazine Column or Ad
- Already know Beth
- Word of Mouth Referral
- Other
Please elaborate on the selection you made above.*
Would you like to be added to our email newsletter full of tips, promotions, special offers and more?*
- Yes
- No
PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT
I wish to participate in the exercise and training program offered by CareerFit Mom (CFM). 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. If I choose not to see a physician prior to beginning a fitness program, I do so strictly at my own risk and against recommendation of CFM. I also agree to provide CFM with my physician’s contact information so that CFM may receive direct clearance and program recommendation/limitations from my physician. I further agree that CFM, Beth Yarzab and/or any fitness professional working with CFM shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, in a training studio, outdoors, or at a corporate, commercial, residential or other fitness facility), and I expressly release and discharge CFM, its owners, employees, agents and/or assigns 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 an 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.
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 requested 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 CFM 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.
I understand that I am not obligated to perform nor participate in any activity that I do not wish to do. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and seek medical attention, if required.*
- I have read and understand this term.
I understand the results of any fitness program cannot be guaranteed and my progress depends on my own effort and cooperation with the fitness program. *
- I have read and understand this term.
I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by CFM.*
- I have read and understand this term.
I understand that CFM may photograph client events/sessions and I provide CFM the absolute right and permission to use these pictures/images for any lawful promotional, advertising or marketing purpose. *
- I have read and understand this term.
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.*
Indicate your agreement by typing your full name.
Date*
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Virtual Training Client Information Questionnaire

Virtual Personal Training - Client Information Questionnaire

PAR-Q FORM

LIFESTYLE RELATED QUESTIONS

FITNESS HISTORY

NUTRITION RELATED QUESTIONS

EXERCISE RELATED QUESTIONS

DEVELOPING YOUR FITNESS PROGRAM

GOAL SETTING

MISCELLANEOUS QUESTIONS

PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT

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