New Client Questionaire

Date*
Name*
First Last
Email*
DOB*
Gender*
Current Weight (lbs.)*
Please give us an indication of your weight as best to your knowledge.
Height (ex. 5ft.2)
Please give us an indication of your Height as best to your knowledge.
Local Address*
Street Address Address Line 2 City State ZIP Code

For Mileage calculations .55 cents per mile
Daytime/Work Phone*
Evening/Home Phone*
Cell Phone*
Fax Number
Best Time to Contact

: HH

MM
Training Interests & Goals
How did you find out about Science of Fitness? Please check all reasons that apply.
Please let us know what fitness services you may be interested in? Please check all reasons that apply.
Why are you looking for a personal fitness trainer? Please check all that apply below, or use the box to enter any other reasons.
Other Training Reasons:
What is the best time to meet for a fitness & nutrition consultation?
Check which area of West Palm Beach County , Fl. you live in.*
Please give a brief description of the health and fitness goals you are trying to achieve or improve.
Nutrition
How many meals do you eat per day?
Do you skip meals?
- Yes
- No
If you skip meals, check which ones you skip on most days?
What time do you eat breakfast?
What time do you eat lunch?
What time do you eat dinner?
Do you eat snacks?
- Yes
- No
If you eat snacks, check all snack times that apply?
What do you normally eat prior to a workout?
What do you normally eat following a workout?
How many times per week do you eat fatty foods, fast foods, or fried foods?
Do you crave sweets or carbohydrates?
- Yes
- No
How many servings of fruits and vegetables do you eat daily? A serving equals 1/2 cup of cooked or raw vegetables, 1 cup of leafy vegetables, 1/2 cup of fresh, frozen or cooked fruit or 1/4 cup of dried fruit.
How many cups of coffee, tea, soda, or other caffeinated beverages do you consume each day?
Are you over sensitive to caffeine?
- Yes
- No
Are you lactose intolerant or allergic to any dairy products?
- Yes
- No
Are you allergic to seafood or shellfish?
- Yes
- No
Are you allergic to soy products?
- Yes
- No
Would you be interested in having your meals prepared for you at your home by our personal chef service?
- Yes
- No
Preparing Fabulous Meals In Your Home is just one of the services that has separated Science of Fitness from all all other fitness programs and why our clients enjoy the highest success rate of any other program.
List all other food allergies.
Are you currently dieting?
- Yes
- No
Are you currently or have you ever taken any product to enhance weight loss?
- Yes
- No
Do you have problems swallowing or taking pills or vitamins?
- Yes
- No
Would you be interested in working with a licensed Dietitian to help you reach your nutritional goals?
- Yes
- No
Supplementation
Do you currently take any over the counter vitamins or nutritional supplements?
- Yes
- No
Check those vitamins that you are currently taking:
List any other vitamins or nutritional supplements that you are now taking below?
Are you currently taking a protein supplement (shakes or bars) to round out your diet?
- Yes
- No
Are you currently taking any type of creatine supplement?
- Yes
- No
Fitness
Are you currently participating in an exercise program?
- Yes
- No
Do you currently have access to a gym facility,clubhouse or have an active membership with a health club?
- Yes
- No
If yes, check the health club below or list it in the "other" box.
If you are a member of the Wanderers Club, International Polo Club or any other private fitness club, Please enter your Membership ID # Below.
Please list three of the most convenient times for you to train in order of preference. Please make sure to mention am or pm next to each time.
How many times a week are you doing some type of cardiovascular fitness (walking, jogging, running, cycling, swimming etc.)?
Check below the types of cardiovascular fitness you currently participate in.
Are you currently weight training as a part of your exercise program?
- Yes
- No
If you are weight training, indicate what type of equipment you are using.
What muscles fatigue quickly while weight training? Check all that apply.
What time do you exercise each day?
Please list all sports you are currently participating in.
Do you currently suffer from any joint pain from a previous injury (tendon, ligament, cartilage, etc.) that prevents you from being as active as you would like?
- Yes
- No
Do you have problems with muscle cramping during exercise or workouts?
- Yes
- No
Is there any reason at all (health or personal) that would limit or prevent you from exercising?
- Yes
- No
If you have exercise limitations, please list the reasons you cannot exercise below.
Have you ever hired the services of a personal trainer before?
- Yes
- No
Would you be interested in purchasing personalized one on one training, training with a buddy, fitness workshops or outdoor fitness classes from Certified Fitness Trainer, Reginald Stewart to help you reach your fitness goals?
- Yes
- No
Lifestyle
Do you consider yourself to have a high stress level?
- Yes
- No
How many hours of sleep do you get on an average night?
What time do you generally go to bed?
What time do you generally wake up?
Do you suffer from insomnia or have trouble sleeping?
- Yes
- No
Do you smoke?
- Yes
- No
If you smoke, how many packs per day?
Do you drink alcohol?
- Yes
- No
If you drink alcohol, how many drinks per week?
Health Information
Indicate if you have had any of the following or if any apply to you:
Section 1
- Heart attack or heart failure?
- Heart Surgery
- Metabolic diseases
- A pacemaker or other heart device
- A heart valve or congenital heart disease
- Pulmonary disease
- A stroke
- Coronary Artery Disease
- If you are a woman , are you pregnant?
- Musculoskeletal or nerve problems
Have you ever had any of the following?
Section 2
- Pain in your chest, neck or jaw?
- Shortness of breath with mild exertion?
- Palpitations, tachycardia, or irregular heart beat?
- Orthopnea or Paroxsmal Nocturnal Dyspnea?
- Intermittent claudication or thrombosis?
- Ankle swelling?
- Heart Murmur?
- Dizziness?
Indicate if you have had any of the following or if any apply to you:
Section 3
- You are a male older than 45 years of age.
- You are a woman over 55 years of age or have had a hysterectomy or are postmenopausal.
- You smoke or have quit smoking in the last 6 month.
- You have blood pressure greater than 140/90.
- You are physically inactive or get less 30 minutes of physical activity on at least 3 days a week.
- You have a total cholesterol greater than 200mg/dL
- You have a close male blood relative who had a heart attack before the age of 55 or a close female relative who had a heart attack before age 65.
- You have diabetes or take medication to control blood sugar.
- Take prescription medication.
- You are more than 20 pounds overweight.
Sign to Agree*
I understand that exercise programs can create physical stress and possible harmful effect. I agree it is entirely my responsibility to consult a physician prior to my initiating an exercise program. I also understand that exercise equipment can cause injury and take full responsibility for my actions or accidental injury and will use the facilities or program with care and caution.
First Last
Comments
This field is for validation purposes and should be left unchanged.

New Client Questionaire

Training Interests & Goals

Nutrition

Supplementation

Fitness

Lifestyle

Health Information

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