Online Personal Training Registration Form Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATION : Name *FirstLastGender? *MaleFemaleAge? *Current Weight (kg)? *kgHeight (cm)? *cmBody Type? *EctomorphMesomorphEndomorphHEALTH HISTORY *History of heart problems, chest pain, or strokeHistory of breathing or lung problemsElevated blood pressureElevated blood cholesterolThyroid conditionDifficulty with physical exerciseMuscle, joint, or back disorder, or any previous injury still affecting youFood AllergyHernia, or any condition that may be aggravated by lifting weightsRecent surgery (last 12 months)Pregnancy (now or within last 3 months) Females OnlyNoneIf you have answered yes to any of questions, please describeList the specific medications that you currently takeLIFESTYLE / What Do You Do For Living?What's the activity level at your job? *none (seated only)Moderate (light activity such as walking)High (heavy labor, very active)Are you a cigarette smoker? *YesNoIf so, how many per day?Previously a cigarette smoker? *YesNoIf so, when did you quit?Please Rate Your Daily Stress Levels *LowModerateHighOn average, how many hours of sleep do you get each night? *More than 10 hours8-10 hours5-7 hoursLess than 5 hoursHow frequently do you travel, either for work or pleasure? *1-2 times a year3-4 times a yearEvery monthEvery weekDo you have a regular exercise program? *YesNoIf yes please list what activities you currently do and how oftenHow many times do you eat per day? *2 times or less3 times4 times5 times or moreHow often per week do you eat away from home?One time2 times4 times6 times or moreAre you allowed to eat meals while at work? *YesNoWhat do you usually eat in breakfast? *What do you usually eat in lunch? *What do you usually eat in dinner? *POSTURE ANALYSIS *Ideal PostureLordosisKyphosisScoliosisCIRCUMFERENCE MEASUREMENT : Neck *Upper Arm *Waist *Hips *Thigh *Calf *SKINFOLD MEASUREMENTS *MaleFemale1 *2 *3 *CARDIORESPIRATORY FITNESS ASSESSMENTS : The 1.5-Mile Runthe time it takes the client to complete a 1.5-mile runMUSCULAR STRENGTH AND MUSCULAR ENDURANCE ASSESSMENTS : PUSH-UP TESTnumber of reps(1 minute)HEALTH AND FITNESS GOALS : What is your primary fitness goal? *Build muscleLose WeightGain strengthGeneral FitnessTraining for an event/specific sportsChronic Disease ManagmentWhat's another goal you'd like to achieve with your coaching program? *Injury RehabImprove my sleepIncreasing the motivationImprove FlexibilityReducing the stressStop SmokingHow frequently would you be able to work out? *2 days a week3 days a week4 days a week5 days a week6 days a week7 days a weekHow much time do you have for each workout? *Less than 30 minutes30-60 minutes30-90 minutesAt what times during the day would you prefer to train? *MorningMid-DayAfternoonEveningWhere will you primarily be working out? *At homeOutdoorsAt a gymBoth at home and at a gymWhat type of equipment do you have access to? *DumbbellsResistance bandsKettlebellsOthersHow Many Meals Do You Want In This Program? *3 meals per day4 meals per day5 meals per day6 meals per dayAre you happy eating the same foods frequently or do you like a lot of variety? *I am happy eating the same foods frequentlyI like a lot of varietyDo you want to use supplements? *YesNoFOODS YOU LIKE *EggsChicken breastSalmonLean beefTunaShrimpbuttermilkfat-free (skim) milklactose-free milkswhole milkBrown riceQuinoaOatsWhole grain breadWhole wheat pastaLentilsApplesBananasOrangesKiwiAvocadoApricotsFigsBroccoliCarrotsBell peppers (red, green, yellow)TomatoesOnionsCauliflowerCucumberSweet potatoespotatoesCabbageLettuceGreen beansEggplantSpinachOlive oilGarlicLemonsFresh SardineAlmondsPistachiosWalnutsCashewsPeanutsOther foods you like Submit
