Physical Fitness, Health & Nutrition Assessment

The fuller picture, so your plan is built around your body, your history and your goals rather than a template.

A Connections Paradise group training session

This one takes a little longer — around fifteen minutes. Answer what you can and leave anything that does not apply blank; we will pick the rest up on your call.

Everything you write here stays between you and your coach.

Health screening, so every movement we give you is safe
Your lifestyle, sleep and stress, not just your training
Nutrition habits worth keeping and the ones worth changing
SMART goals with a date attached

Your assessment

About you

Contact number

Age

Occupation

Address line 1

Address line 2

City

State

Zip code

Health questionnaire

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

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

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 problems, etc.)?

Are you pregnant now or have given birth within the last 6 months?

Have you had a recent surgery?

If you have answered yes to any of the above, please elaborate below

Do you take any medications, either prescription or non-prescription, on a regular basis? What is the medication for, and how does it affect your ability to exercise or achieve your fitness goals?

Lifestyle

Do you smoke? If yes, how many per day?

Do you drink alcohol? If yes, how many glasses per week?

How many hours do you regularly sleep at night?

Describe your job: sedentary, active, or physically demanding

On a scale of 1-10, how would you rate your stress level? (1 = very low, 10 = very high)

Fitness history

When were you in the best shape of your life?

Have you been exercising consistently for the past 3 months?

When did you first start thinking about getting in shape?

What, if anything, stopped you in the past?

Nutrition

On a scale of 1-10, how would you rate your nutrition? (1 = very poor, 10 = excellent)

How many times a day do you usually eat, including snacks?

Do you skip meals? Do you eat breakfast?

Do you eat late at night? Often, sometimes, rarely or never

How many glasses of water do you consume daily?

Do you feel drops in your energy levels throughout the day? If yes, when?

Do you know how many calories you eat per day? If yes, how many?

Are you currently taking, or have you ever taken, a multivitamin or any other food supplements? If yes, please list them

At work or school, do you usually eat out or bring food?

How many times per week do you eat out?

Do you do your own grocery shopping?

Do you do your own cooking?

Besides hunger, what other reasons do you eat? Boredom, social, stressed, tired, depressed, happy, nervous

Do you eat past the point of fullness? Often, sometimes, rarely or never

Do you eat foods high in fat and sugar? Often, sometimes, rarely or never

List 3 areas of your nutrition you would like to improve

Exercise — skip to the next section if you are presently inactive

How often do you take part in physical exercise?

If your participation is lower than you would like it to be, what are the reasons? Lack of interest, illness or injury, lack of time, other

For how long have you been consistently physically active?

What activities are you presently involved in? Cardio and/or sports, frequency per week, average length, easy/moderate/hard

Developing your fitness programme

How and when do you prefer to exercise? Large groups, small groups, alone or a combination — and morning, afternoon or evening

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

Based on your commitment, how often would you like to see a trainer? 3x/week, 2x/week, 1x/week, 1x/two weeks, 1x/month, other

What are the best days during the week for you to commit to your exercise program?

If you could design your own exercise program, what would an ideal training week look like? Please be specific — favourite activities, rest days, time spent, and so on

Goal setting

How can we best help you? Lose body fat, develop muscle tone, rehabilitate an injury, nutrition education, start an exercise program, design a more advanced program, safety, sports specific training, increase muscle size, fun, motivation, other

Please list, in order of priority, the fitness goals you would like to achieve in the next 3-12 months. Keep them SMART: Specific, Measurable, Attainable, Rewards-based and with a Time frame

How important is it for you to achieve these goals? Very, semi or not very

How long have you been thinking about achieving these goals?

How will you feel once you have achieved these goals? Be specific

Where do you rate health in your life? Low, medium or high priority

How committed are you to achieving your fitness goals? Very, semi or not very

What do you think is the most important thing your personal trainer can do to help you achieve your fitness goals?

Outline what you feel are the obstacles that could impede your progress (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, letting other responsibilities take priority over exercise)

Outline 3 methods that you plan to use to overcome these obstacles

Sign off

Today’s date

Signature — type your full name to sign

Guardian’s signature — required for clients 17 years old and younger

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