Client Fitness Consultation Form - Personalized Program Development

Client Consultation Questionnaire

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping me develop a program that addresses your needs, goals, and interests and is safe and effective.

First Name *

Last Name *

Phone *

Email *

Date of birth *

Age *

Address *

City *

Postal code *

Occupation *

Emergency Contact & Relationship *

Emergency Contact Phone Number *

Physician's Name *

Physician's Phone *

PAR-Q FORM

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

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

Have you had chest pain when you were not doing physical activity? *

Do you lose your balance due to dizziness or do you ever lose consciousness? *

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.)? *

Have you had a recent surgery? *

If you have marked YES to any of the above, please elaborate below

Do you take any medications, either prescription or non-prescription, on a regular basis? *

If Yes: What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

Lifestyle Related Questions

Do you smoke? *

If you do Smoke, how many?

Do you drink alcohol? *

If you do drink alcohol, how many glasses per week?

How many hours do you regularly sleep at night?

Describe your job *

Does your job require travel? *

On a scale of 1-10, how would you rate your stress level?

List your 3 biggest sources of stress

1.
2.
3.

Is anyone in your family overweight? *

Were you overweight as a child? *

If you were overweight as a child, what ages?

What is your Height? *

Nutrition Related Questions

(Part 1 of 2)

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? *

What activities do you engage in while eating? (Tv, Reading Etc)

How many glasses of water do you consume daily? *

Do you feel drops in your energy levels throughout the day? *

If yes, when does your energy drop?

Do you know how many calories you eat per day? *

If Yes, how many calories do you eat per day?

Are you currently or have you ever taken a multivitamin or any other food supplements? *

If yes, please list the supplements AND the brands

At work do you usually... *

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 reason(s) do you eat?

Do you eat past the point of fullness? *

List 3 areas of your Nutrition you would like to improve. *

A
B
C

Do you eat foods high in fat and sugar? *

Are there any foods you will not eat? *

Nutrition Related Questions

(Part 2 of 2)

Detail your most typical daily diet including portion sizes, approximate times of day and when you wake, train and sleep. *

Wake-up
Meal 1
Meal 2
Meal 3
Meal 4
Meal 5
Meal 6
Cardio
Train(Include time you typically train.
Sleep

Are there any types of diets that have worked really well for you in the past? *

Goal Setting

Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months? *

1.
2.
3.
4.
5.
6.

Where do you rate health in your life? *

How committed are you to achieving your fitness goals? *

What do you think the most important thing I can do to help you achieve your fitness goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise exercise etc.). *

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

A.
B.
C.

1 = very frequent/serve symptoms

2 = regular symptoms

3 = fairly regular/tolerable symptoms

4 = infrequent/manageable symptoms

5 = rare/minor symptoms

Rate, from 1 - being never to 5 - being often, How much each one applies to you.

Do you perform exercise that noticeably raises your heartbeat for at least 30 minutes more than three times a week?
Do you engage in weight-bearing exercise(weight training, running/jogging, Gymnastics) at least twice a week?
Do you regularly(weekly) play a sport?(football, tennis, squash, karate, etc)
Are you in serious training for a sport or athletic event?
Do you find at least an hour to relax each day?
Do you spend more than 4 hours a day near a busy City or road or exercise by roads?
Do you spend more than an hour a day in heavy traffic?
Do you live, work or spend time in a smoky atmosphere?
Do you eat organic produce?
Do you spend more than 4 hours a day in front of a TV or computer screen?
Do you drink unfiltered tap water?
Do you make time to lie down 45 to 10 minutes 2 to 3 times a day?
Do you take hot and cold alternating showers daily?
Do you thoroughly brush your skin with a skin brush?
Do you do deep breathing exercises?

Energy

Rate these questions on a scale between 1 to 5. 1 being never and 5 being often

Do you easily become exhausted, even after a light exercise?
Do you have a low energy level or generally feel you lack energy?
Have you experienced recent reductions in the amount of energy you have?
Do you suffer from insomnia?
Do you feel you need more than 8 hours of sleep a night? Do you wake in the night feeling anxious or 'nervy'?
When you wake up in the morning do you feel tired or groggy even after a "good sleep"?
Do you need something to get you going in the morning? Ex. Coffee, regular tea, or cigarette.
Do you crave tea, coffee, cola/sodas at regular intervals during the day?
Do you find that you often need to eat something to pick up your energy level?
Do you find yourself craving alcohol at the end of the day/in the evening?
If you haven't eaten for 6 hours do you get headaches, dizzy or irritable?
Do you get excessively thirsty or get thirsty often?

Weight

Rate these questions on a scale between 1 to 5. 1 being never and 5 being often. *

Do you find it hard to lose weight? (or gain weight if underweight?)
Are you gaining weight?

Skin Hair and Nails

Rate these questions on a scale between 1 to 5. 1 being never and 5 being often. *

Do you have brittle, weak, thin or peeling nails or do some(or all) of your nails split easily?
Do you have white marks on more than two fingernails?
Do you get swollen fingers or puffy hands?
Do you have greasy or oily skin?
Do you have vertical ridges on any of your nails?
Do you have poor hair condition(limp, splitting, breaking or thin)?
Is your hair graying early/prematurely?
Do you have dry, brittle hair, a flaky scalp or dandruff?
Is your hair dull or oily?
Have you lost or are losing your hair?

Are you a Female? *

Female Health

Rate these questions on a scale between 1 to 5. 1 being never and 5 being often.

Do you suffer from breast tenderness?
Do you suffer from reduced libido or loss of interest in sex?
Are you prone to thrush or vaginal yeast infections?
Have you taken contraceptives or HRT in the past for more than a year or for 6 months or more in the last 2 years?
Do you experience(cyclical) water retention?
Do you crave particular Foods before your? (Ex. chocolate)
Do you experience menstrual cramps?
Do you suffer from PMS/ PMT?
Are your periods irregular?
Are your periods heavy?
Do you have fertility problems, difficulty conceiving, or a history of miscarriage?
Do you have problems related to menopause?

PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT

I wish to participate in the exercise and training program offered by Titan Training. I understand there are inherent risks in participating in a program of strenuous exercise. I agree that Titan Training shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Titan Training and its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.

I certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform my Personal Trainer of any conditions or changes in my health, now and ongoing, which might affect my ability to exercise safely and with minimal risk of injury.

I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel light-headed, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer.

I understand the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.

I understand that Titan Training bills its Personal Training clients based on a pre-paid basis.

I understand that Titan Training operates on a scheduled appointment basis for all Private Training sessions and thus, requires that I provide 24 hours notice when cancelling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given. Should I cancel a session with 24 hours prior notice, I will be charged $65 for the session. I understand that Titan Training recommends that all cancelled sessions be rescheduled to ensure consistency and fitness progress.

I understand that during a personal training session, my trainer may have to use Touch Training to correct alignment, aid in stretching and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch Training, I will immediately request that my trainer discontinue using this technique.

I understand that Titan Training photographs and videos many of their client events/sessions and I provide written approval for them to use these pictures for promotional purposes.

I understand that programs, advice and dietary plans provided to me are property of Titan Training and I understand that they cannot be shared, reproduced, emailed or used in any way, including social media, without the written consent of a representative of Titan Training.

I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.

Client Consultation Questionnaire Signature *

Clear