Fitness
     Analysis 		     
 
     
 

 

All information submitted to PerfectFit will be kept strictly confidential.

Name
Date of Birth
Current Age
Home Phone
Alternate Phone    
Street Address
City
Postal Code
Marital Status
Email
Physician
Physician's Phone
Physician Address
City
Postal Code

 

Fitness Background - History

Are you presently exercising?
If yes -
Type of exercise
Frequency
Duration
If no - How long have you been thinking of starting an exercise program?
 
What recreational activities do you participate in?
 
How long have you been exercising regularly?
 
Are you happy with your present physical state?
 
When did you feel you were the most satisfied with your physical state?
 
What was your weight at that time?
What is your current weight?
Body fat percentage?
What is your desired weight?
What do you like about your physique?
What do you dislike about your physique?

 

Lifestyle Habits - Behaviour

Occupation
Company
Description of work performed
Hours worked in one week
Days worked in one week
Do you find your occupation stressful?
What do you do for stress release?
Do you smoke?
If yes, how many per day?
Have you ever smoked?
If yes, for how long?
How much do you spend on cigarettes per week?
Do you drink alcohol?
How many drinks per week?
Do you drink coffee?
How many cups per day?
Sleep pattern
How many hours sleep per night?
Energy levels - Morning
Afternoon
Night
Do you have background knowledge of any of these disciplines (check all that apply)?
  Nutrition
  Aerobics
  Body-building
  Resistance training
  Compet-itive running

 

Nutritional Background

On a scale of 1-10, how would you rate your nutrition (1= poor, 10=excellent)
 
Do you know how many calories you intake in a day?
 
If yes, how many?
How many of the following meals do you eat, and what do you typically eat during each meal?
 
Breakfast
Midmorning snack
Lunch
Midafternoon snack
Dinner
Evening snack
Late night snack
Other
List your favourite foods

 

Medical Background

Click any of the following that relate to you
  Arthritis
  Dizziness
  Neck or back pain
  High blood pressure
  Low blood pressure
  Hernia
  Allergies
  Shortness of breath
  Anemia
  Rheumatism
  Rheumatic fever
  Heart or chest pain
  Asthma
  Emphysema
  Water retention
  Heart disease
  Diabetes
  Epilepsy
  Varicose veins
  Heart trouble
  Gastro-intestinal problems
  Irregular bowel movements
  Previous injuries
  Recent surgery
  Bone or joint problems
Are you accustomed to vigorous exercise?  
When you exercise or engage in strenuous activity do you experience any of these symptoms?
  Leg cramps
  Dizziness
  Pain in Neck
  Pain in Upper Back
  Swelling of joints
  Loss of conscious-ness
  Headaches
  Pain in jaw
  Pain in chest
  Coughing
  Pain in shoulders
Are you presently taking any form of medication or supplements?
   
What types?
Is there a physical reason not mentioned why you should not follow a program?
   
If yes, please specify

 

Goals

    
What are the areas you wish to improve?
  Weight loss
  Aerobic capacity
  Muscle toning
  Body-building
  Intensity training
  Nutritional wellness counselling
  Stress manage-ment
  Develop-ment/imple-mentation of a rehab program
  Other
Please list in order of priority 3 fitness-based goals you would like to achieve
1.
2.
3.
Is there any appropriate deadline for these goals?
   
If yes, when?
On a scale of 1 to 10 how important is achieving these goals to you (1 = low, 10 = extremely important)