Fitness Assessment – Personal Changes Training

Date of Birth:

Age:

Gender:

Male Female

Marital Status:

Single Married Divorced

Do you have any children?

Yes No

If yes, how many and what are their ages?

Do you feel that you have a strong support network made up of family members and/or friends?

Yes No Not sure

Do you currently hold a health club/gym membership?

Yes No

If yes, how far from work and/or home is it located?

less than 5 miles 5 - 10 miles 10 miles or more

Do you feel your neighborhood is safe?

Yes No

What is your current occupation?

Are you happy with your current occupation?

Yes No

Does the nature of your occupation require you to sit most of the day?

Yes No Part of the day

Does your occupation require you to travel?

Yes No

If yes, how often do you travel?

less than 1 week a month 2 - 4 weeks a month months at a time

Please detail your exercise history using Exercise, Intensity, Duration, and Frequency to describe.

Exercise- list the type of activity or activities that you participate in; the "work" that you are doing.

Intensity- how hard you perceive the work you do; rank how hard the work you do on a scale of 1 - 10, 10 being the hardest.

Duration- the length of time of each of your exercise sessions.

Frequency- the amount of times per week dedicated to exercise.

Current

Exercise:

Intensity:

1 2 3 4 5 6 7 8 9 10

Duration:

1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours

Frequency:

once a week twice a week 3 times a week 5 times a week daily

Past 12 months

Exercise:

Intensity:

1 2 3 4 5 6 7 8 9 10

Duration:

1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours

Frequency

once a week twice a week 3 times a week 5 times a week daily

Past 5 years

Exercise:

Intensity:

1 2 3 4 5 6 7 8 9 10

Duration:

1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours

Frequency:

once a week twice a week 3 times a week 5 times a week daily

Past 10 years

Exercise:

Intensity:

1 2 3 4 5 6 7 8 9 10

Duration:

1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours

Frequency:

once a week twice a week 3 times a week 5 times a week daily

Other current daily/lifestyle activities (gardening, housework, yard work):

Fitness/Wellness Goals

Short term goals (6 months or less):

Long term goals (6 months of more)

If different from what is listed above, what activities are you interested in now?

Treadmill Outdoor Running Stationary Bike Outdoor Cycling Walking Aquatics Aerobics Elliptical Pilates Yoga Flexibility Resistance Training Others

How much time would you like to dedicate to your physical activity?

Days per week for activity:

1 2 3 4 5 6 7

Time alloted per day:

1/2 hour 1 hour 1 1/2 hours 2 hours 3 or more hours

Please provide the following information if known.

Height:

Weight:

Ideal weight:

Least you have weighed your adult life and when:

Most you have weighed your adult life and when:

Circumferences (inches)

Waist:

Hip:

Neck:

Bicep (R):

Thigh (R):

Calf (R):

Resting heart rate:

Resting blood pressure:

Nutrition

Do you eat breakfast everyday?

Yes No

Do you eat 3 meals a day?

Yes No

If not, how many meals a day?

less than 1 2 4 5 or more

Do you snack throughout the day?

Yes No

If yes, what do you like to snack on?

Do you find yourself skipping meals often?

Yes No

If yes, how often and which meals do you skip?

less than once a week 2 - 4 times a week daily breakfast lunch dinner

Do you get a variety of fruits and vegetables everyday?

Yes No

Approximately how many cups of fruit and vegetables do you consume everyday?

less than 2 2 - 4 5 or more

On average, how many alcoholic beverages do you consume per day?

none 1 - 2 3 or more

per week?

none 1 - 2 3 - 4 5 or more

Do you typically choose whole grain food sources versus refined food sources (i.e. brown rice vs. white rice)?

Yes No

Are you consciously limiting the intake of any of the following:

salt saturated fat caffeine cholesterol red meats trans fats fried foods sugar no

How many days a week do you eat fried food?

less than 2 2 - 4 5 or more

How many times a week do you eat away from home?

less than 1 2 - 4 5 or more

Where do you eat when away from home (mark all that apply)?

fast food car sit down restaurant airport other

What are your typical food choices when eating away from home (mark all that apply)?

fish poultry pork red meat other

Have you been on a special diet recently?

Yes No

If yes, which one?

Have you ever kept a food log?

Yes No

If yes, what type?

handwritten app

Do you have any medical limitations to your diet?

Yes No

If yes, what are they?

What foods do you enjoy?

What foods do you enjoy, but feel you need to restrict?

Do you feel all foods can be eaten if in moderation?

Yes No

Would you like to improve your diet or learn more about how to develop a heathly diet?

Yes No

If yes, how committed are you on a scale of 1 - 10?

1 2 3 4 5 6 7 8 9 10

If you have any specific nutrition goals, please detail below:

Do you often feel stressed?

Yes No

If yes, on average how many days per week?

less than 2 2 - 4 5 or more

Does stress sometimes interfere with your health, personal happiness, or ability to be productive at work?

Yes No

Is your job often stressful?

Yes No

If yes, in what way?

Rank the stress you experience in a typical day on a scale of 1 -5, 5 being extremely stressed and 1 being not stressed:

1 2 3 4 5

Do you get 7 - 8 hours of sleep on a regular basis?

Yes No

Would you consider the sleep you get quality sleep?

Yes No

Are you sometimes unable to relax when you want to?

Yes No

What are some ways that you relax/de-stress?

Have you ever tried exercising as a de-stressor?

Yes No

If yes, what did you do and was it effective?

List some factors that stimulate stress for you:

When you are stressed do you typically:

Please list any specific goals related to stress management below: