Fitness Assessment Form- One-on-One Personal Training and Online Training Service

Consultation Agreement

I agree to the following conditions for the upcoming consultation with my nutritionist/dietitian:

The information I have provided/will provide via questionnaires, phone, email, in-person, or by any other means of communication is accurate to the best of my knowledge.
The recommendations I will receive from my nutritionist/dietitian are not a substitute for medical advice from a qualified doctor.
The advice I will receive from my nutritionist/dietitian is personal and applies to me only. This same advice may be ineffective or even harmful when applied to other people with different backgrounds.
I must communicate to my nutritionist/dietitian any changes in my medical prescriptions or treatments for the duration of my nutrition plan.
I must inform my nutritionist/dietitian promptly if any of my new changes in diet or lifestyle start to cause me adverse effects.
I understand that the advice I shall receive will not be enough to achieve my nutrition or lifestyle goals unless I follow it diligently and commit to it fully.
I understand any changes in my diet and lifestyle may produce effects in my body, energy, health, and condition that are gradual in nature – not instantaneous.
I understand that, although my nutritionist/dietitian will endeavor to help me achieve my nutrition and lifestyle goals to the extent possible, the possibility exists I may not fully attain my goals due to factors outside the control of my nutritionist/dietitian.

Last updated: never

Joel “JayC” Cruz

Personal Trainer | PN Nutritionist | Fitness Coach.

Electronic signature – I have read and understood the terms above and I agree to them.

ALL INFORMATION RECEIVED ON THIS FORM WILL BE TREATED AS STRICTLY CONFIDENTIAL.

Assessing Your Needs:

Please fill out the forms as accurately as possible. This information is essential to develop a program that addresses your needs, goals, and interests in a safe and effective manner.

Coaching Service

One-on-One Personal Training

Online Personal Training

First Name

Last Name

Phone/Mobile

Email

Location

Makati City

BGC Taguig

Pasay City

Other

Age

Gender

Birth date

Height

Weight

Nationality

PAR-Q or Physical Activity Readiness Questionnaire

Being physically active is very safe for most people. Some people, however, should check with their doctors before they increase their current level of activity.

The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.

Answer YES or NO to the following questions:

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

No

2. Do you feel pain in your chest when you do physical activity?

Yes

No

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

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

Yes

No

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

Yes

No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

No

7. Do you know of any other reason why you should not do physical activity?

Yes

No

If you answered NO:

If you answered NO to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have a low risk of having any medical complications from exercise.
It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a personal trainer or coach in order to determine where to begin.

When to delay the start of an exercise program:
If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising.
If you are or may be pregnant, talk with your doctor before you start becoming more active.
Keep in mind, that if your health changes, so that you then answer "YES" to any of the above questions, tell your fitness or health professional, and ask whether you should change your physical activity plan.

Client Fitness Goals (SMART GOALS)

Your goals or aims are what you intend to achieve. Research shows a positive link between people with clearly thought-out goals and their level of success.

In order to increase your chances of being successful at achieving your goals, ensure your goals are “SMART”

S=Specific (provide details, how much, how long, etc)
M=Measurable (how will you measure when you’ve reached your goals)
A=Attainable (be realistic, set smaller goals)
R=Rewards-based (attach a reward to each goal)
T=Time (set specific dates for goals)

Are there any body parts in particular that you wish to improve?

Target body weight in mind?

What are the best times for you to exercise?

Do you have a specific event or date to achieve your fitness goals?

How would you describe your current knowledge of exercise and fitness training?

If you currently exercise, would you say your routine is:

What will motivate you to achieve your goals?

How motivated are you to achieving your goals?

What, if any, are your expected barriers towards your exercise program?

Nutrition History & Consultation

Are you currently on a diet? if yes what method?

Have you ever tracked your food intake (i.e. food diary or app based)?

Yes

No

On average, how many portions of fruit and vegetables do you eat per day?

If you eat snack or have any food weaknesses, what do you generally tend to eat/drink?

How would you rate your current eating habits?

Have you ever been diagnosed with an eating disorder?

Do you take any Vitamin / food supplements?

Are there any foods that you avoid?

Are you a Vegetarian/Vegan?

On average, how many days a week do you consume alcoholic beverages?

What types of alcoholic drinks do you consume?

On average, how many alcoholic drinks do you consume at one time?

How many meals do you eat each day? (include snacks)

Do you ever skip meals?

if yes which ones and how regularly?

How big would you say your meals were?

Small

Medium

Large

Unlimited

Do you ever get hungry between meals?

How often do you eat out on a weekly basis?

Once a week

Twice a week

Other

Do you smoke?

If yes, how many cigarettes per day?

List what you would like to improve in your the nutrition area:

Exercise History / Analysis

Do you currently exercise?

Current Activity level

How would you rate your present level of fitness?

Have you ever had a personal training session?

How long have you been training/exercising?

How often do you train?

once a week

2 times a week

3-4 times a week

Everyday

How long is each training session?

30 minutes

1 hour

More than 1 hour

Where do you exercise?

Home or Condo Gym

Commercial gym

Outdoor

Gym and Outdoor

What type of exercise do you do?

What time of day do you normally train?

Morning

Afternoon

Evening

Anytime

Do you participate in any particular sports?

What DID or DO you like the LEAST about the exercise?

Lifestyle Analysis

How do you spend the majority of your time at work?

Sitting

Standing

Active

Would you characterize your life mostly as:

Low stress

Moderate stress

High stress

How would you consider your current body weight?

Under weight

Normal weight

Over weight

On average How many hours do you regularly sleep at night?

5-6 hours

8 hours

more than 8 hours

How would you describe your current activity level?

Sedentary (no exercise)

Moderately active (little exercise)

Active (regular exercise)

Highly Active

You will be motivated at the start of this process. At some point, your motivation will drop. This is normal and I have ways to fix this. Do not postpone sessions! In fact, the more you struggle, the more I want to hear from you.

Client responsibilities: Be ready for a big challenge. Ask for help as soon as you think you need it.

Be honest.

Do your homework workouts (if I recommended)

Show up to training appointments or reschedule.

Let me know if the plan isn't working. In other words, help me help you. OK?