Fitness Xpress University

Bringing Top Level Training into your Home.

New Client Questionnaire

Instructions: Answer each question as completely and honestly as possible

Personal Information
Date
First Name
Last Name
Date of Birth
Home Phone
Cell Phone
Email (Required)
Address
City
State
Zip
Questionaire

1. Why are you beginning an exercise program? If you have already been exercising why are you securing the services of a personal trainer?

2. What are your goals? Short term and long term. Short-term (3 months):

Long-term (beyond 3):

3. What might hinder your fitness program?

4. What motivates you?

5. How do you learn best? (seeing, hearing, doing)

6. What kinds of exercise programs have you done in the past?

7. What did you like best/least about them?

8. What types of exercise/activity do you enjoy?

9. What is your favorite type of exercise or activity?

10. How much time can you commit to exercise (number of days/week as well as time per workout)?

11. Please list below what your nutritional habits are on a typical day. Please provide food items, time eaten, etc. Just list out a typical day.

Medical History
Date of Last Physical Exam
Are you under the care of a physician?
If yes, please explain
List any allergies
List any medications presently taking by type, dosage & reason
Health Habits
What is your desired weight?
Do you consider yourself
Do you smoke?
Have you ever smoked?
If yes, how many packs per day?
If yes, how long ago did you quit?
Do you currently exercise? If yes, what does it consist of
What activities do you do and duration of each exercise?
Have you ever followed a specific diet?
What do you do for a living?
Supplements
Do you currently take any vitamins?
Have you ever tried any other supplements?
If yes, how was the experience?
Physical Activity Readiness Questionnaire

PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life.

For most people, physical activity should not pose any problems 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 advise concerning the type of activity most suitable for them.

Common sense is your best guide in answering these few questions. Please read the carefully and check YES or NO opposite the question if it applies to you. If yes, please explain.

Y N
	1. Has your doctor ever said you have heart trouble?
	2. Do you frequently have pains in your heart and chest?
	3. Do you often feel faint or have spells of severe dizziness?
	4. Has a doctor ever said your blood pressure was too high?
	5. Has your doctor ever told you that you have a bone or joint problem(s), such as arthritis that has been aggravated by exercise, or might be made worse with exercise ?
	6. Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to?
	7. Are you over age 60 and not accustomed to vigorous exercise?
	8. Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness?
	9. Are you currently taking any medications? If YES, please specify.
	10. Do you currently have a disability or a communicable disease? If YES, please specify.

If you answered NO to all questions above, it gives a general indication that you may participate in physical and aerobic fitness activities and/or fitness evaluation testing. The fact that you answered NO to the above questions, is no guarantee that you will have a normal response to exercise. If you answered Yes to any of the above questions, then you may need written permission from a physician before participating at Fitness Xpress University.

By checking the I agree box below, I acknowledge that even though it is in my best interest to receive medical clearance I hereby agree to assume all risks of such exercise and activities and agree to hold harmless Fitness Xpress University, its officers, and staff from any and all claims, suits, losses or causes of action for damages including, but not limited to, such claims that may result from injury or death, accidental or otherwise, arising in any way from my past or current health status either apparent or otherwise. I have read and understand the aforementioned.

Fitness Xpress University is not an accredited university. We are taking on the theme of a university since we pride ourselves in delivery of high quality fitness information. It is also FXU's position that this site cannot fully replace the one-on-one aspect of personal training. If you have health complications or injuries that require a more hands on approach, FXU can assist in your quest to your reach your goals along with the direct supervision of a qualified fitness professional. By clicking the below "I agree" box, you hereby acknowledge that you have fully read the above statements and have been given the chance to have any questions you may have, answered.

REQUIRED Please check
I agree to the above terms and conditions listed above.