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Assessment Form

Physical Activity Readiness Questionnaire

1. Heart Condition?		If yes, please explain
2. Diabetes?		If yes, please explain
3. Asthma (Uncontrolled)?		If yes, please explain
4. Shortness of breath?		If yes, please explain
5. Arthritis?		If yes, please explain
6. Rheumatism?		If yes, please explain
7. Hernia?		If yes, please explain
8. Recent Surgery?		If yes, please explain
9. Epilepsy?		If yes, please explain
10. Angina?		If yes, please explain
11. High Blood Pressure?		If yes, please explain
12. Knee Problems?		If yes, please explain
13. Shoulder Problems?		If yes, please explain
14. Back Problems?		Cervical / Thoracic / Lumbar?
15. Has a doctor ever said you have heart trouble?		If yes, please explain
16. Do you often feel faint or have spells of severe dizziness?		If yes, please explain
17. Do frequently suffer from pains in your chest		If yes, please explain
18. Has a doctor ever told you that your blood pressure was too high		If yes, please explain
19. Do You have any bone or joint problems		If yes, please explain
20. Is there a good physical reason not mentioned here why you should not follow an activity program?		If yes, please explain
21. Are you currently taking any type of medication?		If yes, please explain
22. Have you consulted a Physician regarding increasing your physical activity and/or having a fitness evaluation?		If yes, please explain
23. If no to question 8 will you consult your physician prior to increasing your physical activity?		If yes, please explain

I certify that the above statements are true and correct(Please type name)
Physician Release Form/Doctor’s note received on: (mm/dd/yyyy)

Goal Assessment

What is your primary goal?
What is your secondary goal?
Years at present weight:
What has been your highest/lowest weight?
Have you ever participated in any weight loss / weight gain program?
When would you say that you were in the best shape of your life?
What activities were you involved in at, that time?
How would you grade yourself on your eating habits?
How many times a day do you usually eat?
Do you feel drops in your energy levels throughout the day?
If yes at what time or times during the day?
Are you taking a multivitamin or any other supplements?
Have you ever used meal replacement drinks or bars?
Have you ever worked with a Nutritionist or a Certified Personal Trainer?
Are currently doing cardiovascular/cardiorespiratory exercise?
- What types?
- How long?
- How often?
Have you ever participated in any type of resistance training program?
Realistically how many days does exercise fit into your lifestyle per week?
Where do you rate health as a priority in your life? Low Priority1 - 5 High Priority
How committed do you feel to improving your health and working toward your goals? Not Committed 1 2 3 4 5 Committed
Do you have a time frame in mind for achieving your goals?
Do you have an exact plan for achieving your goals?
Do you consume alcohol?
Do you smoke cigarettes?
Do you drink coffee?
Do you drink soda pop?
How much water do you drink a day?