APPLICATION – THE DONEGYM

PERSONAL INFORMATION

NAME

ADDRESS

EMAIL

PHONE

PERSONAL PHYSICIAN

DATE OF LAST PHYSICAL

DATE OF BIRTH

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)? YES/NO

Have you ever been diagnosed or treated for any chronic disease including asthma? YES/NO

Are you currently taking any medications? YES/NO

Have you ever had your thyroid hormone levels checked? YES/NO

HEALTH RELATED BEHAVIOR

Do you smoke regularly?

Do you drink alcohol regularly?

How many times on average do you eat fast food per week?

How many hours of sleep do you normally get per night?

PSYCHOLOGICAL

Are you an impatient, time conscious, hard driving individual?

Do you have a positive attitude towards things?

Does your job stress you out?

Are you in the best shape of your life?

How would you rate your current health? (1 – 10)

Are you serious about achieving your goals?

GOALS

Do you have any health related goals (i.e. Lower blood pressure, etc.)?

Do you have any specific goals related to body composition (i.e. Weight loss, build muscle, etc.)?

Do you wish to achieve any of these goals in a specific time frame?

FITNESS INFORMATION

What type of duties do you perform at work?

Have you had any injuries related to physical activity?

Do you suffer from any chronic pain?

Have you ever participated in resistance/weight training before?

Have you ever trained with a personal trainer before?

Are you currently involved in an exercise regimen?

How many days per week do you accumulate 30 minutes of moderate activity?

How many days per week do you accumulate at least 20 minute of vigorous activity (i.e. continuous heavy lifting or sprinting)?

PSYCHOLOGICAL

When would you say you were in the best shape of your life? How did you feel?

How would you rate your current physical fitness? (rate 1 – 10)

My physical fitness is important to me? (rate 1 – 10)

I enjoy exercising? (rate 1 – 10)

I can succeed in achieving my goals? (rate 1 – 10)

GOALS

Do you have any performance related fitness related goals (i.e. increase 10K time, bench press)?

Do you wish to achieve these goals in a specific time frame?

TRAINING PREFERENCES

I enjoy to be pushed (challenged) to the limit. (rate 1 – 10)

I am willing and able to perform recommended exercise (i.e. Cardio, stretching, etc.) on my own time. (rate 1 – 10)

How many personal training sessions per week is desirable?

NUTRITIONAL INFORMATION

Have you worked with a nutritionist or used a diet program (i.e. Weight Watchers) before?

Have you been on a diet before (i.e. Atkins, zone, etc.)?

NUTRITIONAL KNOWLEDGE

Do you know how to differentiate between Carbohydrates, Fats, and Proteins?

Do you understand what a Calorie represents?

Do you understand the concept of caloric balance?

NUTRITIONAL HABITS

How long after you wake up before you consume your first meal on average?

How many times do you eat per day on average?

I eat in response to stress.

FLUID CHOICES

How many cups of water do you drink per day on average (1 cup = 1 glass)?

How many servings of juice/drink (i.e. Snapple, orange juice) do you drink per day on average?

How many servings of regular soda do you drink per day on average (1 serving = 1 12oz. can)?

How many cups of caffeinated beverages (i.e. coffee, tea) do you drink per day?

FOOD CHOICES

How many servings (1 cup or size of fist) of vegetables do you eat per day on average?

How many servings (1 cup or size of fist) of protein (meat) do you eat per day on average?

How many servings (1 cup or size of fist) of carbohydrates (i.e. Potatoes, bread, pasta, cereals) do you eat per day on average?

How many times per week on average do you eat candy & dessert foods?

PSHYCOLOGICAL

I would rate my current diet. (rate 1 -10)

I would rate my self-discipline with regards to eating. (rate 1 -10)

I feel comfortable limiting my food intake by counting calories. (rate 1 -10)

I am serious about achieving my goals. (rate 1 -10)

DIETARY SUPPLEMENTS

Do you currently take any dietary supplements?

Have you taken dietary supplements in the past?

Are you willing to incorporate dietary supplements into your training program.