New Client Profile QuestionnairePlease read each of the following questions carefully and select your answer. Each question is required. PERSONAL DETAILS Name * First Name Last Name Email * Phone Number (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Phone Number (###) ### #### CLIENT QUESTIONNAIRE What goals are most important for you to accomplish while working with me? * Please list the types of activities and exercise you are involved in including hobbies. * Please include frequency, intensity, duration, and effort-level (Effort: 10-0 with 10 being the most demanding). Please list the activities or exercise with which you would like to be involved. * Please describe your relationship with physical activity. * What type of food do you like to eat? * What general percentage of proteins, fats, and carbohydrates do you eat? * How often and at what time do you typically eat each day? * Please describe your relationship with food. * What is your current occupation? * Does your occupation or lifestyle involve extended periods of sitting? * Yes No Does your occupation or lifestyle involve extended repetitive motion? * Yes No Does your occupation or lifestyle cause you to experience stress or anxiety? * Yes No What type of shoes do you wear most often? * Have you ever had any surgeries? * Yes No Do you lose balance due to dizziness or have you ever lost consciousness? * Yes No Do you experience any limitations that restrict your physical ability? * Yes No Could you share your height: * Could you share your approximate weight: * Your birthday: PHYSICAL READINESS QUESTIONNAIRE (PAR Q) Has your doctor or health professional ever told you that you need to limit physical activity? * Yes No Has a medical doctor ever diagnosed you with a heart condition or chronic condition or anything not mentioned here? * Examples include coronary heart disease, coronary artery disease, high blood pressure, high cholesterol, diabetes, epilepsy, and autoimmune diseases. Yes No Have you ever had any injuries or chronic pain? * Examples include bone, joint, soft tissue in head, neck, back, abdomen, pelvis, hips, legs, knees, ankle, and/or foot. Yes No Are you currently taking any medication or supplements that could affect your physical activity or mental state? * Yes No If you answered YES to any of the questions in the PAR Q section, you agree to obtain your doctor's approval before* our first workout meeting (your initial assessment*). In addition, if your circumstances change and you can answer YES to any one of these questions in the future, you agree to obtain your doctor's approval before continuing sessions. Initial the box below to indicate "I agree". HEALTH ASSESSMENT Choose one option for each question. 1. In general would you say your health is: * 1—Excellent 2—Very Good 3—Good 4—Fair 5—Poor 2. Compared to one year ago, how would you rate your health in general now? * 1—Much better now than one year ago 2—Somewhat better now than one year ago 3—About the same 4—Somewhat worse now than one year ago 5—Much worse now than one year ago The following questions are about activities you might do in a typical day. Does you health now limit you in these activities? If so how much? 3. Vigorous activity such as running, lifting heaving objects, or participating in sports * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 4. Moderate activity such as moving a table, pushing a vacuum cleaner, bowling, or playing golf * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 5. Lifting or carrying groceries * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 6. Climbing several flights of stairs * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 7. Climbing one flight of stairs * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 8. Bending, kneeling, or stooping * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 9. Walking more than a mile * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 10. Walking several blocks * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 11. Walking one block * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 12. Bathing or dressing yourself * Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) During the last four weeks have you had any of the following problems with your work or other daily activities as a result of your physical health? 13. Cut down the amount of time you spent on work or other activities Yes (1) No (2) 14. Accomplished less than you would like Yes (1) No (2) 15. Were limited in the kind of work or other activities Yes (1) No (2) 16. Had difficulty performing the work or other activities (eg. typical tasks took extra effort) Yes (1) No (2) During the past four weeks have you had any of the following problems with your work or other regular daily activities as a result of emotional problems (such as feeling anxious or depressed)? 17. Cut down he amount of time you spent on work or other activities Yes (1) No (2) 18. Accomplished less than you would like Yes (1) No (2) 19. Didn't do work or other activities as carefully as usual Yes (1) No (2) 20. During the past four weeks to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups 1—Not at all 2—Slightly 3—Moderately 4—Quite a bit 5—Extremely 21. How much bodily pain have you had during the last four week? 1—None 2—Very mild 3—Mild 4—Moderate 5—Severe 6—Very Severe 22. During the last four weeks how much did pain interfere with your normal work (including both work outside the home and housework)? 1—Not at all 2—A little bit 3—Moderately 4—Quite a bit 5—Extremely These questions are about how you feel and how things have been with you during the last four weeks. For each question, please select the answer closest to how you have been feeling. How much of the time in the last four weeks... 23. Did you feel full of pep? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 24. Have you been a very nervous person? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 25. Have you felt so down in the dumps that nothing could cheer you up? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 26. Have you felt calm and peaceful? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 28. Have you felt downhearted and blue? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 29. Did you feel worn out? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 30. Have you been a happy person? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 31. Did you feel tired? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 32. Has your physical health or emotional problems interfered with social activities (eg. visiting with friends, relatives, etc.)? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) How TRUE or FALSE is each of the following statements for you? 33. I seem to get sick a little easier than other people * Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) 34. I am as healthy as anybody I know * Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) 35. I expect my health to get worse * Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) 36. My health is excellent * Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) Thank you!
