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AGREEMENT OF SERVICES
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ABOUT
LETS WORK TOGETHER
PERSONAL TRAINING
ONLINE FITNESS COACHING
FORMS/RATES
RATES
HEALTH ASSESSMENT
AGREEMENT OF SERVICES
WAIVER
PRESS KIT
BLOG
AGE STRONG QUESTIONNAIRE
Open Form
Application to Age Strong
PERSONAL INFORMATION
Name
*
First Name
Last Name
Email
*
Birth Date
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
(###)
###
####
Physical Activity Readiness (PAR-Q)
Has your doctor ever said you have heart trouble?
*
No
Yes
Do you frequently have pains in your heart and chest?
*
No
Yes
Do you often feel faint or have spells of severe dizyiness?
*
No
Yes
Has a doctor ever said your blood pressure was too high?
*
No
Yes
Do you have any bone or joint problems that might be worse with exercise?
*
No
Yes
Are there any other reasons why you should not follow an activity program?
*
No
Yes
If YES, please explain further:
Are you accustomed to vigorous exercise?
*
No
Yes
PERSONAL HEALTH HISTORY
Has your doctor ever restricted your physical activity?
*
No
Yes
If YES, how?
Do you have any chronic or serious illnesses?
No
Yes
If YES, please describe:
Have you been hospitalized in the last 3 years? (please include outpatient surgeries)
*
No
Yes
If YES, please list with dates:
Are you presently taking any medications?
No
Yes
If YES, please list type and purpose:
Do you have an allergies? (including medications)
*
No
Yes
If YES, please list and describe:
WOMEN'S HEALTH
Are you currently pregnant or have you been in the past year?
No
Yes
If YES, how far along are you or how postpartum are you?
Are you on any hormone replacement therapy? (BHRT)
No
Yes
If YES, please list type and purpose:
Are you on thyroid medication?
No
Yes
If YES, Hypo or Hyper?
Hypo
Hyper
Do you still have a menstrual cycle?
No
Yes
If YES, how many days does your period last?
INJURIES
Please describe any current or past injuries
Please check any of the following injuries you have had and specify which bone, muscle, joint, etc.
*
Broken bone injury
Ligament injury
Tendon injury
Cartilage injury
Joint injury
Joint pain
Muscle strain
Chronic pain
Back injury
Neck injury
Low-back pain
Other
None
If OTHER, please describe:
Are you currently being treated for any injuries?
No
Yes
If YES, please describe the treatment:
CARDIOVASCULAR
Have any of your parents or siblings had heart disease?
*
No
Yes
If YES, was it before the age of 55?
No
Yes
Please check any that apply and indicate the age of onset:
High Blood Pressure - Mother
High Blood Pressure - Father
High Blood Pressure - Sibling(s)
High Cholesterol - Mother
High Cholesterol - Father
High Cholesterol - Sibling(s)
Diabetes - Mother
Diabetes - Father
Diabetes - Sibling(s)
Heart Disease - Mother
Heart Disease - Father
Heart Disease - Sibling(s)
By-Pass - Mother
By-Pass - Father
By-Pass - Sibling(s)
Stroke - Mother
Stroke - Father
Stroke - Sibling(s)
If you have checked any boxes, can you please indicate the age of onset:
Do you currently smoke cigarettes?
*
No
Yes
If YES, how many cigarettes per day?
1-5
5-10
10-15
15-20
20+
DIET & NUTRITION
Is your diet well-balanced?
No
Yes
Somewhat
Are you currently on a diet plan or have interest in nutrition guidance?
*
Not on a diet
Yes am currently following a nutrition plan
Interested in discussing nutrition coaching
Other
What diet plans have you tried?
*
Alkaline
Atkins
DASH (Dietary Approaches to Stop Hypertension)
Flexitarian
FODMAP
Intermittent Fasting or Time Block Eating
Intuitive Eating
Ketogenic
Mediterranean
MIND
Nutrisystem
Raw Food
Weight Watchers
Whole30
Zone
None
Other
If OTHER, please describe:
Do you drink alcohol?
*
No
Yes
If YES, describe your average weekly alcohol consumption:
Describe an average day's breakfast food consumption:
Describe an average day's lunch food consumption:
Describe an average day's dinner food consumption:
*
Describe an average day's snack food consumption:
*
What is your current weight?
What was your weight 1 year ago?
What was your weight 5 years ago?
What was your weight at age 20?
What weight do you feel comfortable at?
*
Are you happy with how your body currently looks and feels?
*
No
Yes
If NO, please explain further:
If NO, what things would you like to change about your body?
LIFESTYLE HABITS
How would you describe your current stress level?
*
I manage stress well.
I manage stress relatively well, but at times I feel pressured and rushed.
I don't handle stress well and always feel pressured and rushed.
Describe your sleep habits?
*
Do you travel for work? If so, how often?
No
Yes
Other
If YES, how often?
Do you commute to work?
No
Yes
If YES, how far and how long?
Do you have children?
*
No
Yes
How do you enjoy spending your leisure time?
EXERCISE HABITS
How physically fit do you feel at the present time?
*
De-conditioned (Mostly sedentary, never workout))
Below Average ( Light Activity) Walking
Average ( Moderate Activity) Regular Cardio
Above Average ( 3-4x /week Exercise routine)
Very Fit ( Exercise daily, training for a sporting event, weight training 5+ years)
Describe your current activity program:
*
Do you have any exercise equipment in your home?
*
No
Yes
If YES, Do you use your home exercise equipment?
No
Yes
Do you belong to a gym or health club?
*
No
Yes
PAIN ASSESSMENT
Are there any particular activites which do not interest you or might cause you pain or discomfort?
No
Yes
If YES, please specify and indicate all areas on the anatomy chart where you feel numbness, pain, tingling, achey or spasms:
Skeletal / Cranium / Skull
Skeletal / Maxilla / Cheekbone
Skeletal / Mandible / Jaw
Skeletal / Clavicle / Collarbone
Skeletal / Scapula / Shoulder Blade
Skeletal / Sternum / Breastbone
Skeletal / Rib Cage
Skeletal / Humerus / Upper Arm Bone
Skeletal / Radius / Forearm Bone
Skeletal / Ulna / Forearm Bone
Skeletal / Carpal / Wrist Bones
Skeletal / Metacarpal / Hand Bones
Skeletal / Phalanges / (Proximal, Middle and Distal) / Finger Bones
Skeletal / Illum / Upper Hip Bone
Skeletal / Pubis / Pubic Bone
Skeletal / Ischium / Lower Hip Bone
Skeletal / Femur / Thigh Bone
Skeletal / Patella / Kneecap Bone
Skeletal / Tibia / Calf Bone
Skeletal / Fibula / Calf Bone
Skeletal / Tarsals / Ankle and Heel Bones
Skeletal / Phalanges / (Proximal, Middle and Distal) / Toe Bones
Muscular / Facial Muscles
Muscular / Sternocleidomastoid / Neck Muscle
Muscular / Trapezius / Back Muscles (Traps)
Muscular / Deltiods / Shoulder Muscles (Delts)
Muscular / Latissimus Dorsi / Back Muscles (Lats)
Muscular / Erector Spinae / Spinal Erectors
Muscular / Rhomboids / Back Muscles
Muscular / Triceps / Back, Upper Arm Muscles
Muscular / Biceps / Front, Upper Arm Muscles
Muscular / Extensors / Forearm Muscles
Muscular / Obliques / Side Abdominal Muscles
Muscular / Abdominals / Stomach Muscles (Abs)
Muscular / Gluteal Muscles / Buttock Muscles (Gluts)
Muscular / Quadriceps / Thigh Muscles
Muscular / Hamstring Muscles
Muscular / Gastrocnemius and Soleus / Calf Muscles
Muscular / Calcaneal Tendon / Achilles Tendon
FITNESS GOALS
What is your primary reason for seeking out a personal trainer?
*
What specifically do you want me to help you with?
*
What short-term goals do you have concerning your fitness and health?
*
What long-term goals do you have concerning your fitness and health?
*
READINESS
Do you feel more strongly that: (choose one)
*
Given the right advice, you can work your way back to optimal health.
You can find the right person or treatment that will provide the answer to your problems.
What is a higher priority for you at this moment in time: (choose one)
*
Improve and manage symptoms.
Identify and work on causative factors.
How much would you be willing to adapt your current lifestyle based on your assessment findings?
*
Not at all
Slightly
Moderately
Significantly
Completely
On a scale of 0-10, will your TIME investment prove the biggest challenge to you successfully completing your program? (0 = no challenge and 10 = significant challenge
*
0
1
2
3
4
5
6
7
8
9
10
On a scale of 0-10, will your FINANCIAL investment prove the biggest challenge to you successfully completing your program? (0 = no challenge and 10 = significant challenge
*
0
1
2
3
4
5
6
7
8
9
10
On a scale of 0-10, will your ENERGY investment prove the biggest challenge to you successfully completing your program? (0 = no challenge and 10 = significant challenge
*
0
1
2
3
4
5
6
7
8
9
10
What will you commit to in order to achieve your goals (# days/week, lifestyle changes, etc.)?
*
What are you willing to give up in order to achieve your goals
*
CAT OR DOG PERSON?
CAT
DOG
I LOVE THEM BOTH!
Thank you! Your application has been submitted! I look forward to speaking with you soon!
