FITWELL COACHING

Physical Activity Readiness Questionnaire

General Information

First name: Last name:

Address:

City: Zip Code:

Home Phone: Work Phone: Cell Phone:

Email Address:

Date of Birth: Age: Marital Status: Married Single Other

Occupation: Company: Years:

Goals, General Health History, Background

Describe your general health: Excellent Very Good Good Fair Poor

Height (Feet / Inches: Current Weight:

Please list your goals in any of the below areas, and list priority level (1-5) where 1 is the highest level of priority.

Fitness:

Stress Mgmt:

Health:

Other:

Check the appropriate goals and add details where possible.

Increased energy/productivity:

Improved appearance:

Feel/look younger:

Improved muscle tone:

Increased Muscle Mass:

Decreased stress:

Better sleep:

Improved self esteem:

Decreased depression:

What is the first issue you’d like to work on with your coach?

How would you describe your ideal coach?

What are your scheduling preferences? (Days and times you are most available)

What days and times are you not available?

What is your preferred training style? No-nonsense Patient/Nurturing Hybrid Other:

Is there anything else that your coach should know?

Current Physical Activity

Select your current level of activity:

Sedentary

Mildly active (occasional, but not regular)

Active (moderate exercise, several times a week)

Very active (moderate exercise almost every day)

Describe any fitness programs or physical activities you have engaged in during the last 10 years and describe the results and lessons, if any, were learned:

Current limitations on physical activity (e.g., knee injury prevents walking):

Previous limitations on physical activity (over the last 10 years):

Do you currently engage in any of the following exercise programs or activities?

Aerobics (fast walking, jogging, etc.):

Stretching: :

Strength training (weight lifting):

Other:

Describe your exercise routine in the past week:

Describe type and minutes or hours of weekly recreational physical activities (such as social dancing, gardening, yard work, walking from train station to job)

Describe efforts to incorporate more activity in daily life (such as taking the stairs instead of the elevator; parking once for errands and then walking):

Physical activities enjoyed the most:

Physical activities you dislike:

Physical activities you would like to try:

Please list fitness equipment you own:

Describe how you use that equipment or used it in the past:

Do you currently belong to a health club or regularly participate in classes?

Energy Level and Metabolism

Time of day when energy level is the Highest: Lowest:

Stress Management

Describe your general level of stress: (Ex. Low Medium High & details)

Describe the impact daily stress has on your health: (Ex. Low Medium High & details)

Describe in detail typical daily and weekly and weekend schedules (time you wake up, work schedule, evening activities)

How do you feel when you wake up most mornings?

How do you feel when you go to sleep most nights?

Describe sleep problems:

Describe likely cause of sleep problems:

Describe and rank the things that cause you the greatest stress:

Describe the measures to reduce stress in your life that you have tried over the past ten years, and the results and lessons learned:

Medical History

1. Has a physician ever said you have a heart condition and you should only do physical activity recommended by a physician? Y N

2. When you do physical activity, do you feel pain in your chest? Y N

3. When you were not doing physical activity, have you had chest pain in the past month? Y N

4. Do you ever lose consciousness or do you lose your balance because of dizziness? Y N

5. Do you have a joint or bone problem that may be made worse by a change in your physical activity? Y N

6. Is a physician currently prescribing medications for your blood pressure or heart condition? Y N

7. Are you pregnant? Y N

8. Do you have insulin dependent diabetes? Y N

9. Are you 69 years of age or older? Y N

If you answered “YES” to any of the above questions, talk with your doctor BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answer yes.

If you honestly answered “NO” no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually.

If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.

Is your doctor currently prescribing any drugs for any heart condition, including heart rhythm, blood pressure, coronary artery

disease, or high cholesterol? Y N

Has any family member died of a heart attack before age 50? Include your parents, grandparents and siblings. Y N

What is your most recent blood pressure reading, when was it taken, and by whom?

What is your current resting heart rate (if known)? BPM

Have you been diagnosed as having bradycardia (too low of a heart rate) or trachycardia (too fast of a heart rate)? Y N

What is the date of your last physical or medical examination?

List surgeries that you have had, including any operations on your back, eyes, hernia, bones, heart, kidneys, neck, ears, lungs, other:

Have you had any surgeries in the past three months? If so, what type?

List current medications, if any:

Have you any limitations in your range of motion of any of your limbs, or your torso? Y N

Do you often feel faint or have spells of severe dizziness? Y N

Has a doctor ever told you that you have a bone or joint problem such as arthritis that might be aggravated by exercise? Y N

Do you ever experience an irregular or racing heart rate during exercise or at rest? Y N

Are you over the age of 65 and not accustomed to vigorous exercise? Y N

Has a doctor ever said that your blood pressure is too high? Y N

Is there any reason not mentioned above why you should NOT follow an activity program? Y N

If YES, please explain:

Do you smoke? Y N How much?

Have you smoked in the last ten years? Y N How much?

Do any of the following conditions exist – currently or in the past?

IMPORTANT!: By clicking the SUBMIT button at the bottom of this form you are affirming the above information is true and correct to the best of your knowledge and are clicking the SUBMIT button in lieu of physically signing the form in the studio.

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