Health Assesment Form

Health Assessment

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Preferred Method Of Contact *

Email Phone No Preference

Date of Birth *

Age *

Age You Feel *

Emergency Contact *

First

Last

Emergency Number *

Occupation *

What Type of Duties Do You Perform at Work? *

Location You Would Like Training *

How Often Would You Like To Train With a Trainer? *

What Length Of Training Session Are You Interested In? *

What is your weekly availability?

Please Give Us Your TOP 3 Days/Times From Above That You Think Might Be BEST for You to TRAIN and be the Most Successful! *

Have You Ever Worked With a Personal Trainer Before? *

No Yes

If you answered yes, How did it go for you? *

Are You Currently Involved in an Exercise Routine? *

No Yes

If you answered yes, Please Briefly Describe Your Regimen? *

What is Your Current Fitness Level? *

If You Have Been Inactive, Please Briefly Explain for How Long and Why? *

What Areas of Your Overall Fitness/Health Do You Want To Improve? *

Please Elaborate on Any Specific Goals (i.e. Weight Loss, Tone Muscle, Improve Strength, Balance & Flexibility Performance etc.)? *

Are these Goals Time Bound? (wedding, vacation, etc.) *

No Yes

Any Additional Reasons for Seeking Out a Trainer? *

At What Level Do You Feel You Exert Your Body While Exercising? *

Do You Enjoy Being Pushed (Challenged) to Your Limits or Beyond? *

Yes No

Will You Perform Suggested Exercise Routine on Your Own Time? *

Yes No

Medical History

Are you Currently taking any medications? If Yes, Please list them. *

Do You Have Any Current Health Concerns We Should Know About? *

Have You Had Any Family History of Chronic Disease (Heart Disease, Diabetes, Etc.? *

Are You Concerned About Any Type of Personal Health Conditions or Family History of Health? *

Yes No

Have You Had Any Injuries Related to Physical Activity? If Yes, Please list. *

Date of Last Check-Up? *

Do You Smoke? If Yes. How Much? *

Do You Drink? If Yes, How Much? *

My Diet

What % of Healthy Food Do You Feel You Consume? *

How Many Times a Day Do You Eat on Average? *

Do You Eat in Response to Stress Levels? *

Yes No

How Often Do You Eat Fast Food? *

How Often Do You Eat VEGETABLES? *

How Often Do You Eat PROTEIN? *

How Often Do You Eat CARBOHYDRATES? *

How Often Do You Eat DESSERT(S)? *

How Many Cups of Water Do You Drink in a day? (1 glass=1 Cup) *

How Many Cups of Juice (i.e. Snapple, Orange Juice, Arizona Tea) Do You Drink Per Day on Average? (1 Glass=1 Cup) *

How Many Cups of Soda Do You Drink Per Day on Average? (1 Serving=1 12oz Can) *

How Many Cups of Caffeinated Beverages Do You Drink Per Day? (8,10,12,16,20 oz) *

Are you currently on or Have You Ever Followed a Weight Loss/Diet Program ? (i.e. Atkins, Keto, Paleo) Before? If Yes, What Were the Results? *

How Many Hours Do You Sleep At Night? *

On a Scale of 1-10 (1 Being Low and 10 Being High) How Would You Rate:

Energy Level During Day: *

CardioVascular Endurance: *

Ability to Cope with Stress: *

Back & Core Function: *

Physical Appearance: *

Body Fat: *

Muscle Mass: *

Posture: *

Ability to Relax/Sleep: *

PAR-Q & YOU

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active everyday. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions.

Please read the questions carefully and answer each one honestly

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (e.g., water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity? If so, please explain in the comment section below before submitting.

Please select one of the responses according to how you answered the PAR-Q questions *

If you answered NO to all questions, you can be reasonably sure you can:
- start becoming much more physically active -- begin slowly and build up gradually. This is the safest and easiest way to go.
- take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.
If you answered YES to at least one (1) question,
- Click HERE to download the paper PAR-Q Form
- Print the form and follow the instructions pertaining to answering YES to 1 question.

Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Policies and Procedures

Thank you for taking part in private training. Below are the policies and procedures that allow CNFC Staff to be the most efficient and provide the best service possible.

Cancellation Policy:
All cancellations must be received at least 24 hours before your scheduled training session. Clients who do not cancel with 24 hours notice will be charged for the scheduled session. If you need to cancel a session, please call your Trainer.

Tardiness Policy:
Your appointment will take place only between the timeframe booked regardless of when you arrive. Please be on time to benefit from a full session.

Refund Policy:
We strive to provide the best possible service to our clients. If for any reason you are not satisfied with our Training services, we will be happy to rematch you with another Trainer and/or discuss a credit to your account. All training packages are non-refundable.

Lincoln Park Fitness Center, Ravenswood Fitness Center, and Edgewater Fitness Center together will hereinafter be referred to as Chicago's Neighborhood Fitness Centers ("CNFC").

I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with CNFC and STAFF. I also agree and understand if I choose to purchase private training sessions through CNFC AND choose in-home instruction, I, the undersigned, assume all risks connected therewith and consent to participate in said program at the chosen alternate off-site location. Having such knowledge, I hereby release CNFC, their representatives, agents, and successors from liability for accidental injury or illness which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program. I ALSO UNDERSTAND THE POLICIES AND PROCEDURES REGARDING PERSONAL TRAINING. *

Your typed full name & today's date shall act as your signature *

Is there any additional information your would like us to know that has not been shared above? (Also, you may answer question 7 of the PAR-Q here) *

Submit

Ravenswood Fitness Center
1958 W Montrose Ave
Chicago IL 60613
773-784-0732

Edgewater Fitness Center
1106 W Bryn Mawr Ave
Chicago IL 60660
773-728-2660

Lincoln Park Fitness Center
444 W Fullerton Pkwy
Chicago IL 60614
773-281-8715

Member Access
4am - 11pm
7 Days/Week

Staffed Hours
Varies By Location
(Check Our Locations Page For Details)
All Locations Not Staffed
New Years Day, Easter Sunday, Memorial Day, 4th of July, Labor Day, Thanksgiving Day, Black Friday, Christmas Eve, Christmas Day, and New Years Eve

Account Access

Chicago’s Neighborhood Fitness Centers strives to be your lifelong partner in fitness and wellness by practicing the mantra “Be Healthy, Stay Healthy”.

Health Assessment

What is your weekly availability?

​Medical History

​My Diet

PAR-Q & YOU

Policies and Procedures

Medical History

My Diet