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Free In-Home Fitness & Wellness Assessment

Contact Info

* Required fields.
Full Name: *
Email:
Primary Phone:
 
Secondary Phone:
 
Street Address:

City:
State:
Zip: *
How may we help you?
Preventive health & wellness Strength / toning Weight loss / management Nutrition & meal planning
Flexibility & joint health Rehab / therapeutic health Core / balance Herbology & anti-aging
Healthier digestion Osteoporosis prevention Postural & spinal health Improved brain function
 
Please describe what you'd like to accomplish, in detail:

    Is your location non-smoking?
Strictly Some smoking indoors
 
How may we contact you?
By phone By email By text message By Facebook

Health History

Birthdate: Gender:
Month Day Year
Male Female
Height: Weight:
Primary Physician Name: Emergency Contact Name:
Primary Physician Phone: Emergency Contact Phone:
   

Health History


Have you ever suffered a definite or suspected stroke?   Yes No
Have you had an abnormal EKG, coronary bypass surgery or any other heart surgery?   Yes No
Do you have any other cardiovascular or pulmonary (lung) disease other than asthma, allergies, or mitral valve prolapse?   Yes No
Within the past 12 months, has a health professional told you that you have high blood pressure? Definition: Systolic over 140 or diastolic over 90   Yes No

Health History


Have you taken any medications to control your blood pressure in the past 12 months?   Yes No
Do you have pain or discomfort in the chest or surrounding areas when you engage in physical activity?   Yes No
Do you experience difficulty breathing, unexplained dizziness, fainting, or recurrent swelling of the ankles (unrelated to injury)?   Yes No
Do you experience any pain in the legs that would cause you to stop walking (claudication)?   Yes No
Do you experience heart palpitations (irregularity or racing of the heart)   Yes No

 

 

Health History

Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?   Yes No
Are you under treatment for blood clots?   Yes No
Have your father or brother had heart disease prior to age 55? Or, have your mother or sister had heart disease prior to age 65?   Yes No
If a health professional has set any limits or restrictions on your physical activity, then please describe those.

Do you have a history of diabetes, thyroid disease, kidney disease, or liver disease? Please be specific.

Health History

Is it possible that you are pregnant? If yes, what is your expected due date?
Have you been diagnosed with fibromyalgia, or suffered from any other bone, joint, or muscle issue that may be aggravated with exercise? Please explain.
Have you been a cigarette smoker within the past six months? If so, then please explain.
Do you have any other conditions that may hinder your ability to exercise?
Examples are asthma, mitral valve prolapse, epilepsy, history of rheumatic fever, cancer, anemia, hepatitis or other such conditions.

Health History

If you have experienced any sudden, unexplained weight loss or weight gain at any time in the past six months, then please describe.
Are you currently being treated for any other medical condition?
Please list all prescriptions and over-the-counter medications that you are currently taking. List dosage and frequency of use.

Exercise History

Over the past 90 days, roughly how often have you exercised?
How would you describe your attitude towards exercise, in general?
Do you consider yourself to be someone who has a hard time sticking with an exercise regimen?
What will happen to you if you decide not to begin health & fitness training? Consider both physical and psychological repercussions.

Preferences

Do you have a preference regarding the gender of your fitness professional?
If a trainer of that gender is not available, will you be willing to train with a fitness professional of the opposite gender?
Are you interested in Training for Two or Group Sessions?
How many days per week do you see yourself meeting with a Perfect Personal Trainer?
If you decide to begin fitness training, what are the most ideal days of the week and starting times for your 55-minute sessions? (use AM/PM) Ex: Mon, Wed, Fri between 5:30PM & 7:30PM

Preferences

If we cannot meet the schedule described above, then please offer alternative starting times and days of the week for your sessions. (use AM/PM)
Ex: Tues & Thurs between 5PM & 7PM; Sat between NOON & 4PM
Ex2: Mon, Wed, Fri between 6AM & 7AM

What qualities would best describe the ideal fitness professional for you?
Please enter any special concerns, questions, or additional notes here. If the location in which you'd like training is not your home, then please enter the correct zip code and/or location here.

Informed Consent

If the information entered on this form is accurate and you knowingly assume the risks of injury, bodily harm, or death associated with the services offered by Perfect Personal Training (PPT), then please sign your name below as you entered it earlier in this questionnaire. Exercise, nutrition, lifestyle coaching, and all other provided services do involve some level of risk, and PPT cannot be held responsible for any damages to any persons or property. Signing below also authorizes PPT to discuss any medical conditions, drug therapies, and/or lifestyle factors with your physician or care providers, as they pertain to your safety and well-being.