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BODiZONE Preliminary Questionnaire
  Personal Information
First name
    

Last name
    
Date of birth
    
Home Phone
    
Business Phone
   
Address
      
Country
      
State/Province
  
City
       
Postal/Zip code
    
E-mail address
    
Confirm E-mail address
    
How did you hear about BODiZONE?:
Which location are you interested in?
 
  Exercise History
1.  Do you presently exercise? 
2. 

If yes, what type of exercise?

3. 

How often?

4.  Tell us about your current exercise program:  
 
5. 

When did you feel most satisfied with your physical state and why?

 
 
6. 

What is your occupation?

7. 

What do you do for stress relief?

8. 

Do you smoke? 
9. 

How many hours do you sleep each night?

  Medical Background
1.  Please indicate if you have any of the following health conditions: 
Please Explain:
2. 

Are you accustomed to vigorous exercise?

3. 

Are you pregnant?

   Mths
4.  Are you presently taking any medications?
  If yes, please list:
  Nutritional Background
1.

Please indicate which meals and what foods you eat daily:

  Breakfast
 

Mid-morning snack

 

Lunch
  Mid-afternoon snack
 

Dinner
  Evening snack
 

Other
2.  Please list all supplements that you are presently taking:  
 
3.  How many glasses of water do you consume daily?
4.  How many glasses of wine, beer or cocktails do you drink
per week on average?
 Desired Results You Wish To Achieve
1.  Increase Lean Muscle and Strength:
2.  Fat Loss:
3.  Improve Overall Health and Fitness:
4.  Total Body Transformation:
5.  Other:
6.  Do you wish to train for a specific event, occasion or sport?
  If yes, please indicate:
 
7.  What do you see as your greatest hurdle to achieving your health and fitness goal(s)?
 
8.  Are you interested in in-home personal training?
9.  If yes, please list all equipment that you have in your home:  
 
Please answer the following questions before your first appointment with your BODiZONE Personal Trainer .(If you are between the ages of 15 and 69, this test will tell you if you should check with your doctor before you start exercising. If you are over 69 years of age, and you are not accustomed to being very active, check with your doctor.)
  Please read these questions carefully and answer each one honestly with yes or no:
1.  Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2.  Do you feel pain in your chest when you do physical activity?
3.  In the past month, have you had chest pain when you were not doing physical activity?
4.  Do you lose your balance because of dizziness or do you ever lose consciousness?
5.  Do you have a bone or joint problem (for example, back knee, or hip) that could be made worse by a change in your physical activity?
6.  Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7.  Do you know of any other reason why you should not do physical activity?
 
IF YOU ANSWERED
 

No to all questions you can be reasonably sure that you can take part in the following fitness testing and start becoming more physically active. It is also recommended that you have your blood pressure tested. If you have a reading over 144/94, talk with your doctor before you start any fitness program.

 

Yes to one or more questions.Talk to your doctor BEFORE you start becoming much more physically active or BEFORE you complete the fitness testing.

Tell your doctor about this questionnaire and which questions you answered yes.

By clicking below I confirm that I have read, understood and completed this questionnaire. I understand that all exercise carries with it a certain amount of risk and I assume all responsibility for any injury, accident or harm that may come form my participating in this program.
 
 

Those who do not find time for exercise will have to find time for illness

-- Earl of Derby
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