Contact Information
Last Name

First Name
   
Work Phone

Home Phone

Mobile Phone

Email
                    

How did you hear about my servies and/or web site?

Personal / Lifestyle Information
Gender   Male Female

Age    Birth Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Height  4 5 6 7 ft 0 1 2 3 4 5 6 7 8 9 10 11 in

Has your body weight fluctuated in the past 1-5 years?  + 5-10 lbs + 10-20 lbs + 20 or more lbs - 5-10 lbs - 10-20 lbs -20 or more lbs Not much fluctuation Other

What was your weight at age 18? lbs

How may hours of sleep do you typically get a night? 2-4 Hours 5-6 Hours 7-8 Hours 8+ Hours

Do you or have you smoked?  Yes No  If so, when, and how many a day? Never Have Smoked Presently, Less Than 1 Pack a Day Presently, More Than 1 Pack a Day Quit 1-3 years ago; Less Than 1 Pack a Day Quit 1-3 years ago; More than 1 Pack a Day Quit 4-6 years ago; Less Than 1 Pack a Day Quit 4-6 years ago; More Than 1 Pack a Day Quit 7+ years ago; Less Than 1 Pack a Day Quit 7+ years ago; More Than 1 Pack a Day
Do you live with someone who smokes?  Yes No

Do you drink alcoholic beverages?  Yes No  If so, which do you consume, and how much of each? (Click all that apply below:)
  Beer (12 oz); 1-3 Beer (12 oz); 4-6 Beer (12 oz); 7+ Wine (6 oz); 1-3 Wine (6 oz); 4-6 Wine (6 oz); 7+ Liquor (1.5 oz); 1-3 Liquor (1.5 oz); 4-6 Liquor (1.5 oz); 7+

Comments:

Do you travel often for work?  Yes No  If so, how often, and does it have an effect on your exercise?

Did someone refer you or recommend you begin exercising?  Yes No 
If so, who? Doctor Friend Sibling Spouse Other

Exercise History
Are you currently involved in a regular exercise program?  Yes No

How often do you exercise?  (Exercise, for now can be defined as any consistent physical activity, i.e. walking, jogging, lifting weights, or rec sports lasting more than 30 minutes continually at a time.) 
Never Rarely 1 x / week Several x / week Daily

Workout Venue    Webster Groves Fitness Center Home Outside (Walk/Run) Other
What is other venue?
                   
How long have you been a member at Webster Groves? Just Joined 1-4 Weeks 1-3 Months 4-10 Months 1-2 Years 2+ Years

What does a typical workout consist of?  (This can be any consistent physical activity you participate in.) Click all that apply, then please comment in the box below to give me an idea of a typical workout:

"Typical Workout" Details"

Tell me about your very last workout (Continue below or tell me more yourself): 
I warmed up with . . . My cardio consisted of . . . For strength, I did . . .

How long did your workout last? 0-30 min 30-60 min 1-1.5 hrs 1.5+ hrs  

What did you do, more or less? (Choose all that apply by Ctrl-clicking each selection)  Cardio Strength Stretching Ab Workout Other

What was your focus? (Choose all that apply by Ctrl-clicking each selection) Burning Calories Strength Work off stress Preparing for event Not sure of focus Other

Please include any other useful details below: (i.e. did you feel better or worse at the end of the workout?)
I felt ready to take on the world upon exiting the building!

Personal Medical History
Do you have any allergies?  Yes  No
Do you take any medications for these allergies?  Yes  No
If you do take medications, please list them below.
Med , dosage , x / day

Do you take any "over the counter" non-prescribed medications daily? (i.e. Aspirin, Tylenol)  Yes No

Have you had any surgeries that may have an effect on your exercise performance?  Yes  No
List and briefly describe below:
Surgery, Year, Any post-surgical complications?

Do you have any other aches and pains (i.e. low back) that hinder or may hinder your exercising?  Yes No

Have you ever been diagnosed with, or experienced any of the following? (Click all that apply)

Do you take medications for any of the conditions selected here?
For my hypertension, I take . . .

Family Medical History
If known, please click on all of the following conditions your parents, grandparents, or siblings have or have had:

Questions for FEMALES Only
Have you ever been pregnant?  Yes No  If so, how many times? Never 1 2 3 4 5 6 7 8 9 10+

Are you currently expecting?  Yes No    If so, (Congratulations!) what is the present due date?   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Do you have regular menstrual cycles?  Yes No

Are you Pre-menopausal Post-menopausal

Goals Overview (Select all that apply)

Please add any other goal related specifics (in your own words) below:

In a nutshell, what motivates you?  What motivates you to work towards the goals listed above?  What has motivated you in the past?


Please discuss any specific motivators above, and check anything that may apply, included in the list below:

What has happened, if ever in the past, that may have caused you to lose this motivation, or fall off track?
Did not see any results
Got bored
Not enough direction, not really sure what to do or how to progress with exercise
Personal life experience (Career change, had baby, injury, other)
Too busy with work and/or family, (long hours, lots of travel, family obligations)
It just happened, I don't really have that great of an excuse
Other, please explain:

Commitment
How many days a week can you or are you willing to commit to these goals?  (Give or take a day)   1 2 3 4 5 6 7

How much time do you have per workout session? 0-30 min 30-45 min 45-60 min 60+ min It varies from day to day

You can use Reddy H & P as often as you can or want, therefore, how many times do you think you'll want to meet to get you on track?
  Once, to establish a program 2-3 times, to establish program 1 x / week, until I feel comfortable on my own 2+ x / week, for now

Nutrition
How would you rate your nutritional habits as of today?  10 - Right On Track 9 8 7 - Good during the week? 6 5 - Could be better 4 3 - At least my breakfast is OK 2 1 - Supersize That Please!

Do you normally eat breakfast? Yes No      What was your breakfast this morning?  Is this typical?

Are you a vegetarian?  Yes No

How many meals do you typically eat in a day? (A snack is considered a meal.)  1 2 3 4 5 6 7

How much caffeine do you consume daily?  (Cup of coffee = 100 mg , 12 oz soda = 50-60 mg , tablet = 200 mg)
                          None 50-100 mg 100-150 mg 200+ mg Not Sure

What form is it in?  Coffee Regular Soda Diet Soda Tea Energy Drink Other

How many times do you eat out a week?  1-2 3-5 5-7 8+

Do you or have you supplemented with any of the following (Check all that apply):

Can you give me specifics, type of protein, what individual vitamins, what brand fat burner?

How would you describe your "nutritional focus"?
I have no nutritional focus 
Low Fat 
Low Carb 
Everything in moderation
Small portion sizes
Grilled chicken & spinach during the week, wings and beer on the weekend
Other (Explain below):

Do you follow, or have you followed a specific diet?  If so, check the appropriate one and explain below.
South Beach  Atkins  Weight Watchers  Jenny Craig  Zone Diet  40-30-30
Other

Fitness Information
Where do you get most of your health and fitness information?  (Click all that apply.)
Fitness Magazines Internet Newspaper Doctor Other Magazines TV
Book(s) Other

Have you ever ordered a fitness product online? (Book, DVD, Exercise Equipment)

Scheduling An Appointment / Availability
I'm at the Heights on and off, 6 days a week, Monday to Saturday, but have many time slots that are scheduled far in advance.  Therefore, let me know a few available hours and or days that are good for you.  (Click all that apply by holding down the Ctrl button while you select.)

Days
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Time Slots
Early Morning
Mid to Late Morning
Lunch Time
Mid to Late Afternoon
After work or later

Let me know if you have any other questions or comments.

Thank you for taking the time.  Please click the SUBMIT button only once, it may take a minute to process.