Dynamic Massage

Health & Lifestyle Questionnaire

The information you provide below will be used by Dynamic Massage and Personal Fitness personnel to design a customized training program that is best suited for you. All information will be kept private and confidential.

* These are required fields that must be filled in order for the form to work.

Alternatively, if you would like to fill out a questionnaire by hand, please click here to open the printable PDF form in a new browser window. (If you would like to save a copy on your own computer, right-click and choose "Save target as")

CONTACT INFORMATION

* Name:

Date of Birth:

Year:

Month:

Day:

Address:

Suite:

Street:

City:

* Phone:

E-mail:

Preferred method of contact:

Phone

Regular mail

Emergency contact name:

Relationship:

Phone:

CURRENT HEALTH STATUS

Has your doctor ever said you have a heart condition and recommended only medically supervised medical activity?

Yes
No

Do you frequently have pain in your chest when you perform physical activity?

Yes
No

Do you ever lose your balance due to dizziness or do you ever lose consciousness?

Yes
No

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back or neck problems, asthma, etc.)

Yes
No

Are you pregnant now or have you given birth in the last six months?

Yes
No

Have you had surgery in the last six months?

Yes
No

If you have answered 'YES' to any of the above, please elaborate:

Do you take any medications, vitamins or herbs, either prescription or non-prescription on a regular basis?

Yes
No

What is this medication for?

Does this medication affect your ability to exercise or achieve your fitness goals?

Yes
No

How so?

LIFESTYLE

Do you smoke?

Yes
No

How much?

How many hours or sleep do you regularly get per night?

Describe your job:

Sedentary

Active

Physically demanding

Does your job require travel?

Yes
No

Select one to rate your stress level on the scale below:

List your three biggest sources of stress:
1.
2.
3.

Is anyone in your family overweight? (Check all that apply)

Mother
Father
Siblings
Grandparent
Children

Were you overweight as a child?

Yes
No

What age? to years old

FITNESS HISTORY

When were you in the best shape of your life?

When did you first start thinking of getting in shape?

What, if anything, stopped you in the past?

Select one to rate your current fitness level on the scale below:

NUTRITION

Check one to rate your nutrition level on the scale below:

How many times day do you usually eat (including snacks)?

Do you skip meals?

Yes
No

Do you eat breakfast?

Yes
No

Do you eat late at night?

Yes
No

What activities do you engage in while eating? (T.V., reading, driving, etc.)

How many glasses of water do you drink per day?

Do you feel drops in your energy levels throughout the day?

Yes
No

When?

Please list any multivitamins or meal replacement supplements you are currently taking:

Indicate which you normally do at work or at school :

Eat out
Bring lunch from home

How many times per week do you eat out?

Do you do your own grocery shopping?

Yes
No

Do you do your own cooking?

Yes
No

Besides hunger, what other reason(s) do you eat? (Check all that apply)

Boredom
Stress
Social
Tired
Depressed
Happy
Nervous
Other

Do you eat past the point of fullness?

Yes
No

List some areas of nutrition you want to improve:

EXERCISE

How often do you take part in physical activity?

If your participation is lower than you would like it to be, what are the reasons?

How long have you been consistently physically active for?

What activities are you currently involved in? (Please indicate frequency/week, duration and level of difficulty.)

DEVELOPING YOUR FITNESS PROGRAM

How do you prefer to exercise?
(Check all that apply.)

Indoors
Outdoors
Combination
Morning
Afternoon
Evening

Realistically, how often would you like to exercise per week?

Realistically, how often would you like to work with a trainer?

times per week, OR

times per month, OR

times per year

What are the best days of the week for you to be able to commit to an exercise program? (Check all that apply)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

GOAL SETTING

Please check all the ways that a personal trainer can help you achieve your goals:

Lose body fat
Rehabilitate an injury
Start an exercise program
Safety
Develop muscle tone
Nutrition education
Develop a more advanced program
Sports-specific training
Increase muscle size
Motivation
Fun
Other - specify:

In order to increase your chances of being successful in achieving your goal(s), a certain protocol should be followed. Please ensure your goals are 'SMART' :
S = Specific
M = Measurable
A = Attainable
R = Rewards
T = Time Frame

I will achieve this goal by being SMART:

S	=
M	=
A	=
R	=
T	=

I will achieve this goal by being SMART:

S	=
M	=
A	=
R	=
T	=

I will achieve this goal by being SMART:

S	=
M	=
A	=
R	=
T	=

Where do you rate health in your life?

Low priority
Medium priority
High priority

How committed are you to achieving your personal fitness goals?

Very
Semi
Not very

What do you think is the most important thing your personal trainer can do to help you achieve your personal fitness goals? (Remember: we are here for YOU!)

Outline what you feel are the obstacles or your potential actions, behaviours or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, allowing other responsibilities to get in the way of exercise, etc.)

Outline three methods that you plan to use to overcome these obstacles:

1.
2.
3.

MISCELLANEOUS

How did you hear about us?

If you were referred to us, who told you about our services?

Is there any other information that your trainer should be aware of?

When done, please or form