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Please answer as many of the questions as possible, if you do not want to answer anything please leave it blank.
Part 2, contact details, Health, Lifestyle and Current fitness
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Name
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First
Last
Email
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Phone Number
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Name of emergency contact
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First
Last
Emergency contact Phone Number
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Emergency contact email
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Health
Has your doctor ever said that you have a heart condition or recommended that you should only do physical activity while supervised?
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Yes
No
Do you ever have frequent pains in your chest when you perform physical activity?
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Yes
No
Have you had chest pain when you were not doing physical activity?
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Yes
No
Do you lose your balance due to dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone, joint, or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? *
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Yes
No
If applicable: Are you pregnant now or have given birth within the last 6 months?
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Have you had a recent surgery?
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Yes
No
Elaborate any questions to which you replied YES:
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Do you take any medications, either prescription or non-prescription, on a regular basis? If yes, what is it for?
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How does this medication affect your ability to exercise or achieve your fitness goals?
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Lifestyle
Do you drink alcohol (and how much?)
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I do not drink
few pints/drinks a week
Moderate drinker
Heavy drinker
Alcholic
Do you smoke (and how much?)
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Used to smoke
Never smoked
Light/occasional smoker
Medium/regular smoker daily
Heavy smoker
How many hours do you sleep per night?
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less than 4
4-6
6-8
more than 8
What are your biggest sources of stress?
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Is you job
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Sedentry
Active
Very Physically demanding
Mixture
Does your job require travel? How long is the commute?
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Were you overweight as a child?
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Yes
No
Is anyone in your family overweight?
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When did you first start thinking about getting in shape?
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Fitness/Activity
When were you in the best shape of your life?
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Have you been exercising consistently for the past 3 months?
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For how long have you been physically active?
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How often do you take part in physical exercise per week?
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If your participation is lower than you would like it to be, what are the reasons?
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What activities are you presently involved in, and how often? (Cardio, strength training, stretching, etc.)
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On a scale of 1-10, how would you rate your present fitness level (1=worst 10=best)?
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1
2
3
4
5
6
7
8
9
10
Realistically how often per week would you like to exercise?
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How much time per session?
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Where are you likely to do your workouts?
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What kind of help do you want from your personal trainer?
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Nutrition
On a scale of 1-10 how would you rate your nutrition (1=very poor 10=excellent)?
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1
2
3
4
5
6
7
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9
10
How many times a day do you eat? Including snacks?
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Do you skip meals?
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Yes
No
Occasionally
Do you eat late at night?
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Yes
No
Occasionally
What activities do you engage in while eating?
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How many glasses of water do you consume daily?
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Do you feel drops in your energy throughout the day? When?
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Do you know how many calories you eat per day? How many?
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Are you currently taking multivitamin or other food supplements? Which?
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At work or school, do you usually eat out or do you bring your own food?
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Do you do your own cooking?
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Besides hunger, what other reasons do you eat?
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Boredom
Social
Stressed
Tired
Depressed
Happy
Nervous
Do you eat past the point of fullness?
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Do you eat foods high in fat and sugar?
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Would you like nutritional coaching?
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Yes
No
Maybe
What specific areas of nutrition do you want to know about?
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Send
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