Health Assessment

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Health Assessment

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Location you would like Training? *

What service are you interested in? *

What length of sessions fit your needs best? *

Date of Last Checkup: *

Emergency Contact *

Emergency Phone: *

Date of Birth *

Age: *

Age You Feel? *

Occupation *

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)? YES / NO IF YES please list *

Are you currently taking any medications? YES / NO IF YES please list *

Do you have any current health concerns we should know about? *

Health Related Behavior

Do you smoke? YES / NO IF YES how much *

Do you drink alcohol regularly? YES / NO IF YES how much? *

How many times on average do you eat fast food per week? *

How many hours of sleep do you normally get per night? *

What type of duties do you perform at work? *

Have you had any injuries related to physical activity? YES / NO If YES please list *

Are you concerned about any type of personal health conditions or family history of health conditions? *

Have you ever trained with a personal trainer before? YES / NO IF YES, was it successful for you? *

Are you currently involved in an exercise regimen? YES / NO IF YES, please list forms of exercise: *

Describe your current fitness habits. *

If you have ever played sports, when and for how long? *

If you have been inactive, please explain for how long? *

Evaluate Yourself

Rate your personal satisfaction (10=Excellent, 1= Very Poor)

Energy Level during Day *

Cardiovascular Endurance *

Ability to Cope with Stress *

Lower-Back functionality *

Your Physical Appearance *

Body Fat *

Muscle Mass *

Posture *

Ability to Relax/Sleep *

Overall Fitness Level *

What is your current Fitness Status? *

At what level do you feel you exert your body while exercising: *

Nutrition

How many times do you eat per day on average? *

Do you eat in response to your Stress Level? *

What % of healthy food do you feel you consume? *

How many servings of VEGGIES do you eat daily? *

How many servings of PROTEIN do you eat daily? *

How many servings of CARBS do you eat daily? *

How many DESSERTS do you eat daily? *

How many cups of water do you drink per day on average (1 cup = 1 glass)? *

How many cups of juice (i.e. Snapple, orange juice) do you drink per day on average? *

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? *

Have you worked with a Dietician or used a diet program (i.e. Weight Watchers) before? YES / NO If YES what were the results? *

Have you been on a diet before (i.e. Atkins, zone, etc.)? YES / NO If YES what were the results? Were you able to maintain your loss? *

Is there any Nutrition areas you need help with? *

Creating a Healthy Lifestyle!

What areas of your overall Health do you want to improve? *

Please elaborate on any specific body composition goals (i.e. Weight loss, build muscle, etc.)? *

Please list any specific Fitness goals and/or timeframes of completion: *

Any additional reasons for seeking training? *

Please list any areas in your emotional state you would like to improve: *

Do you need help creating a healthy lifestyle plan inclusive of Fitness, Nutrition, Daily habits, Positive thinking, Stress reduction,etc *

Training preferences

I enjoy to be pushed (challenged) to the limit. *

I will perform prescribed exercise on my own time. *

How often would you like to personal train? *

If available, I prefer to train with: *

Please indicate which days and times you are available for Training sessions.

MONDAY *

TUESDAY *

WEDNESDAY *

THURSDAY *

FRIDAY *

SATURDAY *

SUNDAY *

Please name your TOP 3 days/times that you think might be BEST for you to TRAIN and be the most SUCCESSFUL! *

Important!

Please READ this FILE and ELECTRONICALLY SIGN IF YOU ANSWERED "NO" TO ALL QUESTIONS. IF you need DOCTORS CONSENT, please PRINT and have your DOCTOR sign at your next CHECK-UP BEFORE you start to TRAIN.

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 Ravenswood & Edgewater Fitness Centers and STAFF. I also agree and understand if I choose to purchase private training sessions through Ravenswood & Edgewater Fitness Centers 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 Ravenswood & Edgewater Fitness Centers, 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. *

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.

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