Contact Information

Last Name

First Name
   
Work Phone

Home Phone

Mobile Phone

Email
                    

How did you hear about the Webster Groves Fitness Group and/or web site?

If "Other", how did you hear about us?

Is it OK if we add your name to our Quarterly Newsletter / Program Update Email List? (Emails go out every 4-5 times a year to update and announce new programs.) Yes No

Would you like to receive our Injection of Strength email that goes out (almost) once a month? (A short email, but packed with tips, videos, and blog posts developed by our team.) Yes No

Have you spoken with or scheduled an appointment with one of our coaches? If so, please check the box next to his or her name below.

Personal / Lifestyle Information

Gender   Male Female

Age    Birth Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Height  4 5 6 7 ft 0 1 2 3 4 5 6 7 8 9 10 11 in

Approximate Weight at 18-20 Years of Age: lbs

Approximate Current Weight: lbs (enter here or type "discuss" if you would rather discuss in person.)

Did someone refer you or recommend you begin exercising or join a program?  Yes No 

If so, who? Doctor Friend Sibling Spouse Other

Marital Status Married Single

(Females) How many times have you been pregnant? 0 1 2 3 4 5 6 7

Do you have children? Yes No 

If so, how many, what are their ages and how many total then live in your household?

How many hours of sleep do you typically get each night? 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5+

What time do you typically go to bed? 8:00 pm 8:30 pm 9:00 pm 9:30 pm 10:00 pm 10:30 pm 11:00 pm 11:30 pm 12:00 am 12:30 am or later (Shift Worker)

What time do you typically wake up, and do you do so naturally, or to an alarm clock? 4:00 am 4:30 am 5:00 am 5:30 am 6:00 am 6:30 am 7:00 am 7:30 am 8:00 am or later Natural Alarm Clock (Assisted)  

Exercise History

Are you currently involved in a regular exercise program?  Yes No

How often do you exercise?  (Exercise, for now can be defined as any consistent physical activity, i.e. walking, jogging, lifting weights, or rec sports lasting more than 30 minutes continually at a time.) 
Never Rarely 1 x / week Several x / week Daily

Workout Venue    Fitness Center or Health Club Home Outside (Walk/Run) Other

What fitness center or "other venue"?
                   
How long have you been a member at your present health club / fitness center? Just Joined 1-4 Weeks 1-3 Months 4-10 Months 1-2 Years 2+ Years

What does a typical workout consist of?  (This can be any consistent physical activity you participate in.) Click all that apply, then please comment in the box below to give me an idea of a typical workout:

Tell me about your very last workout (Continue below or tell me more yourself): 
I warmed up with . . . My cardio consisted of . . . For strength, I did . . .

What was your focus? (Choose all that apply by Ctrl-clicking each selection) Burning Calories Strength Work off stress Preparing for event Not sure of focus Other

Please include any other useful details below: (i.e. did you feel better or worse at the end of the workout?)
I felt ready to take on the world upon exiting the building!

Physical Activity Readiness Questionnaire (PAR-Q)

For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Please read and check the yes or no opposite the question.

*If your health changes and answers above are altered, please notify your Fitness Coach, and we will discuss seeking guidance from a physician.

Personal Medical History

If you do take medications, please list them below.
Med , dosage , x / day

Have you had any surgeries, injuries, aches or pains that may have an effect on your exercise performance?  Yes  No
List and briefly describe below:
Surgery, Year, Any post-surgical complications?

Have you ever been diagnosed with, or experienced any of the following? (Click all that apply)

Do you take medications for any of the conditions selected here?
For my hypertension, I take . . .

If you are over the age of 60, have you had a bone density test recently? Yes No

A Few Words About Your Goals

Can you please describe your "short term" goals?

Can you please describe your "long term" goals?

In a nutshell, what motivates you?  What motivates you to work towards the goals listed above?  What has motivated you in the past?

What has happened, if ever in the past, that may have caused you to lose this motivation, or fall off track?

Did not see any results
Got bored
Not enough direction, not really sure what to do or how to progress with exercise
Personal life experience (Career change, had baby, injury, other)
Too busy with work and/or family, (long hours, lots of travel, family obligations)
It just happened, I don't really have that great of an excuse
Anything else? Please explain:

Commitment

How many days a week are you willing to commit to these goals?  (Give or take a day)
   1 2 3 4 5 6 7 Would like to discuss this with you

How much time do you have per workout session? 0-30 min 30-45 min 45-60 min 60+ min It varies from day to day

Nutrition

How would you rate your nutritional habits as of today?  10 - Right On Track 9 - Good But With Questions Still 8 7 - Good during the week? 6 5 - Could be better 4 3 - At least my breakfast is OK 2 1 - Supersize That Please!

Do you normally eat breakfast? Yes No     

What was your breakfast this morning?  Is this typical?

Are you a vegetarian?  Yes No

How many meals do you typically eat in a day? (A snack is considered a meal.)  1 2 3 4 5 6 7

How much caffeine do you consume daily?  (Cup of coffee = 100 mg , 12 oz soda = 50-60 mg , tablet = 200 mg)
  None 50-100 mg 100-150 mg 200+ mg Not Sure

What form is it in?  Coffee Regular Soda Diet Soda Tea Energy Drink Other

How many times do you eat out a week?  1-2 3-5 5-7 8+

Are you currently taking any dietary supplements?

How would you describe your "nutritional focus"?
I have no nutritional focus 
Low Fat 
Low Carb 
Everything in moderation
Small portion sizes
Grilled chicken & spinach during the week, wings and beer on the weekend
Other (Explain below):

Do you follow, or have you followed a specific diet and/or for any particular reason or recommendation (Diabetes, Celiac, etc)?  If so, check the appropriate one and explain below.
South Beach  Atkins  Weight Watchers  Jenny Craig  Zone Diet  40-30-30
Other

Health & Fitness Information

Where do you get most of your health and fitness information?  (Click all that apply.)
Fitness Magazines Internet Newspaper Doctor Other Magazines TV (Dr. OZ, etc)
Book(s) Other

Have you ever ordered a fitness product online? (Book, DVD, Exercise Equipment)

Scheduling An Appointment / Availability

To match your goals with our programming and services, we offer the following choices. Please choose something that closely matches what you are envisioning, and we will further discuss this when we meet the first time. You are not committing to anything at this point, just giving us an idea on how to prepare for our initial few sessions so we can get on the same page that much sooner. (If your primary goal is to lose weight and improve your overall health and lifestyle, please choose the Health-Fitness Planning option below, and we will schedule free consultation to discuss what this monthly investment includes.)
  A One Time Consultation A 3 Session Assessment & Exercise Basic Program Continued Exercise Coaching 1-3 x/week Health-Fitness Coaching & Planning Signing Up for a Group Program

In the text box below, please tell us your available days and times of day that are good for you. This is very important to answer as it may determine what trainer is available during this time. Thank you. 

Let me know if you have any other questions or comments.

Thank you for taking the time.  Please click the SUBMIT button only once, it may take a minute to process.