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Fitness & Wellness Request Form - Personal/Partner Training or Pilates Reformer

2. 

3. Fitness and Wellness Request Form
   Please complete this form if you are interested in participating in Personal Training, Partner Training, Small Group Training or Pilates Reformer.

   Please complete this form if you are interested in participating in Personal Training, Partner Training, Small Group Training or Pilates Reformer.

5. I am interested in participating in:*

   1. Personal Training

   1. Partner Training

   1. Small Group Training

   1. Pilates Reformer

7. Participant Information

9. Name (First & Last)*

10. Birthdate (MM/DD/YY)*

12. Email Address*

14. Residential Address*

16. City*

17. State*

18. Zip*

20. Daytime Phone*

21. Cell

23. How did you hear about this service?*

25. Additional Participant Information (if applicable)

27. Name (First & Last)

28. Birthdate (MM/DD/YY)

30. Daytime Phone

31. Cell

33. Trainer/Instructor Preference

35. Trainer/Instructor Requested*

36. Trainer Bio's
    Click Here

37. Availability *

    List times/days

39. Goals *

    List goals below

41. Current Physical Activity Level

43. How many days per week do you exercise?*

    1. 0-1
    2. 2-3
    3. 4-5
    4. 6-7

44. How many minutes do you spend exercising per workout?*

    1. 1-15
    2. 15-30
    3. 30-45
    4. 60+

45. Where do you exercise?*

    1. Gym
    2. Home
    3. Other

47. Why do you exercise?*

    1. I don't
    2. It's good for me
    3. It makes me feel good
    4. I'm trying to lose weight
    5. I'm required to exercise/my doctor told me to

48. Are you involved in a structured fitness program?*

    1. Yes
    2. No

49. Have you had an InBody 570 body composition scan?

    1. Yes
    2. No

51. PAR-Q (Physical Activity Readiness Questionnaire)
    For most people physical activity should not pose any problem or hazard. The Physical Activity Readiness Questionnaire 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. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

    For most people physical activity should not pose any problem or hazard. The Physical Activity Readiness Questionnaire 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. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

53. PARTNER #1

54. PARTNER #2

56. Question 1*

    Has your doctor ever said you have a heart condition AND that you should only do physical activity recommended by a doctor?

    1. Yes

    1. No
57. Question 1

    Has your doctor ever said you have a heart condition AND that you should only do physical activity recommended by a doctor?

    1. Yes

    1. No
59. Question 2*

    Do you feel pain in your chest when you do physical activity?

    1. Yes

    1. No
60. Question 2

    Do you feel pain in your chest when you do physical activity?

    1. Yes

    1. No
62. Question 3*

    In the past month, have you had chest pain when you were not doing physical activity?

    1. Yes

    1. No
63. Question 3

    In the past month, have you had chest pain when you were not doing physical activity?

    1. Yes

    1. No
65. Question 4*

    Do you lose your balance because of dizziness or do you ever lose consciousness?

    1. Yes

    1. No
66. Question 4

    Do you lose your balance because of dizziness or do you ever lose consciousness?

    1. Yes

    1. No
68. Question 5*

    Do you have a bone or joint problem that could be made worse by a change in your physical activity?

    1. Yes

    1. No
69. Question 5

    Do you have a bone or joint problem that could be made worse by a change in your physical activity?

    1. Yes

    1. No
71. Question 6*

    Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition?

    1. Yes

    1. No
72. Question 6

    Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition?

    1. Yes

    1. No
74. Question 7*

    Do you know of ANY OTHER REASON why you should not do physical activity?

    1. Yes

    1. No
75. Question 7

    Do you know of ANY OTHER REASON why you should not do physical activity?

    1. Yes

    1. No
77. If you answered YES to questions 1, 2, 3, 4 or 7...
    Talk with your doctor and have them fill out a Report of Physical Examination form (available at Guest Service) BEFORE you participate in a personal fitness training or fitness assessment. Tell your doctor about the PAR-Q and which questions you answered yes to.

    Talk with your doctor and have them fill out a Report of Physical Examination form (available at Guest Service) BEFORE you participate in a personal fitness training or fitness assessment. Tell your doctor about the PAR-Q and which questions you answered yes to.

79. If you answered NO to all of the questions you can reasonably be sure that you can...
    Start becoming more physically active, beginning slowly and building up gradually. This is the safest and easiest way to go. Take part in personal fitness trainer or fitness assessment appointment; this is an excellent way to determine your basic fitness so you can plan the best way for you to live actively. You should delay becoming more physically active if you are not feeling well because of temporary illness such as a cold or fever OR if you are or may be pregnant. Please consult your physician before coming physically active.

    Start becoming more physically active, beginning slowly and building up gradually. This is the safest and easiest way to go. Take part in personal fitness trainer or fitness assessment appointment; this is an excellent way to determine your basic fitness so you can plan the best way for you to live actively. You should delay becoming more physically active if you are not feeling well because of temporary illness such as a cold or fever OR if you are or may be pregnant. Please consult your physician before coming physically active.

81. Health History Questionnaire

83. Have you ever had any of the following?

    1. Abnormal EKG
    2. Arthritis
    3. Asthma
    4. Auto-Immune
    5. Blood Clots
    6. Cancer/Chemotherapy

    1. Diabetes
    2. Eczema
    3. Epilepsy/Seizures
    4. Heart Attack
    5. Heart Disease
    6. Heart Surgery

    1. High Blood Pressure
    2. Hypoglycemia
    3. Intestinal Disease
    4. Lung/Pulmonary Disorder
    5. Muscular Dystrophy

    1. Multiple Sclerosis
    2. Rheumatoid Arthritis
    3. Surgery
    4. Other
    5. None of the Above

85. Have you ever had an injury, surgery, or problem with any of the following areas?*

    1. Neck
    2. Elbow
    3. Knee
    4. Back

    1. Wrist
    2. Ankle
    3. Shoulder

    1. Hip
    2. Feet
    3. None of the Above

87. If yes to any of the above, please elaborate:

89. Do you currently have any muscle tightness or pain in your body? Please elaborate:

91. Are you currently taking any medications? Please list:

93. Do you have any other physical restrictions or health conditions that your trainer should know about? Please describe:

Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit Submit and Print

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