Client Assessment Step 1 of 10 10% Date of Joining DD slash MM slash YYYY Date of Birth DD slash MM slash YYYY Name(Required) First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender Male Female Email(Required) Phone(Required)CNIC BACKGROUND Your marital status? Single Married Divorced Widowed Do you have children? Yes No Your children details Do you have a strong support network of family and/or friend? Yes No Do you currently hold health club membership ? Yes No If so, how far from home or work is it? Is your neighborhood safe? Yes No What is your current occupation? Are you happy with your current job? Yes No Is the nature of your job mostly inactive or sedentary? Yes No If your job requires travel, how often do you travel? EXERCISE HISTORY Please Describe your exercise history in detail Using Exercise, Intensity, Duration and Frequency. Exercise: The type of activity or activities that you participate; the type of work that you do . Intensity: Rank on a scale of 1-10 (10 being hardest) how hard you perceive this present this workout to be. Duration: The length of time of each of your exercise sessions workouts or physical activity. Frequency:The number of times per week dedicated to exercise or vigorous physical activity. CURRENT Exercise Treadmill Aqatics Bootcamp Outdoor Running Aerobics Resistance Traning Stationary Bike Elliptical Cross-Fit Outdoor Cycling Pilates Zumba Walking Yoga Intensity12345678910Duration15 – 20 minutes25 – 30 minutes40 – 60 minutes1 hour and 15 minutes1 hour and 30 minutes2 hoursFrequency PAST 12 MONTHS Exercise Treadmill Aqatics Bootcamp Outdoor Running Aerobics Resistance Traning Stationary Bike Elliptical Cross-Fit Outdoor Cycling Pilates Zumba Walking Yoga Intensity12345678910Duration15 – 20 minutes25 – 30 minutes40 – 60 minutes1 hour and 15 minutes1 hour and 30 minutes2 hoursFrequency PAST 5-10 YEARS Exercise Treadmill Aqatics Bootcamp Outdoor Running Aerobics Resistance Traning Stationary Bike Elliptical Cross-Fit Outdoor Cycling Pilates Zumba Walking Yoga Intensity12345678910Duration15 – 20 minutes25 – 30 minutes40 – 60 minutes1 hour and 15 minutes1 hour and 30 minutes2 hoursFrequency Daily/Lifestyle Activity? Gardening Housework Yard work Other Daily/Lifestyle Activity? FITNESS & WELLNESS GOALS We’re keen to learn more about your short and long term wellness goals. Short term goalsThree months or lessLong term goalsThree months or moreUnless different from what you listed above, tick activtes that interest you now: Treadmill Aqatics Bootcamp Outdoor Running Aerobics Resistance Traning Stationary Bike Elliptical Cross-Fit Outdoor Cycling Pilates Zumba Walking Yoga Other activity? How much time would you like to dedicate to your physical activity?Days per week for activity0 Days1 Day2 Days3 Days4 Days5 Days6 DaysAll WeekTime alloted per dayPlease enter a number from 0 to 24.(in hours) NUTRITION Do you eat breakfast daily? Yes No Do you eat 3 meals a day? Yes No If not, how many? Do you snack throughout the day? Yes No If yes what do you like to snack on? Do you find yourself skipping meals often? Yes No If yes, which meals? Do you get variety of fruits and vegetables everyday? Yes No How many cups of vegitables do you consume everyday? How many alcoholic beverages do you consume per day? Per week? Do you typically choose whole grain food sources vs. refined foods? Yes No How many days a week do you eat fried foods? Are you consciously limiting the intake of any of the following (please tick) Salts Caffeine Red Meats Fried Foods Saturated Fats Cholesterol Trans Fats Sugar STRESS RELAXATION Do you often feel over-stressed? Yes No If yes,how many days per week on average?1234567Does stress interfere with your health, happiness or productivity? Yes No Is your job (or housework) often stressfull? Yes No Sometimes If yes, in what way? Rank the stress you experience in a typical day on a scale of 1-5 (5=very stressfull)12345Do you get 7 to 8 hours of sleep on a regular basis? Yes No Would you consider the sleep you get quality sleep? Yes No Are you sometimes unable to relax when you want to? Yes No What are some ways to relax/de-stress? Have you ever tried exercise as a de-stresser? Yes No If yes, what did you do and was it effective? List some factors that stimulate stress for you:Please check one, when you are stressed, do you typically? Over eat Under eat Eat the same Please check one, when you are stressed, do you typically? Over exercise Under exercise Exercise the same Please check one, when you are stressed, do you typically? Gain weight Lose weight Maintain the same weight HEALTH HISTORY Heart Disease Personal Father Mother G-Father G-Mother Uncle Auntie Sibling Stroke Personal Father Mother G-Father G-Mother Uncle Auntie Sibling High Cholesterol Personal Father Mother G-Father G-Mother Uncle Auntie Sibling High Blood Preasure Personal Father Mother G-Father G-Mother Uncle Auntie Sibling Diabetes Personal Father Mother G-Father G-Mother Uncle Auntie Sibling Lung Disease Personal Father Mother G-Father G-Mother Uncle Auntie Sibling Cancer Personal Father Mother G-Father G-Mother Uncle Auntie Sibling Do you currently use tobacco products? Yes No If yes, how long and many times a day? If you used tobacco products in the past, when did you quit? Are you exposed to second-hand cigarette smoke? Yes No If yes, in what environment? State any issue below (Past or Current)Muscel issues (Past/Current)PastCurrentBone issues (Past/Current)PastCurrentJoint issues (Past/Current)PastCurrentAny limitations/pain/Discomfort/other concerns: Over Eat Under Eat Eat The Same Medication What medicines do you take?Do you ever have pain in your chest or heart? Yes No Do you ever feel faint or have dizzy spells? Yes No Have you had any surgeries in the last 6 months? Yes No Are you currently pregnant? Yes No Any other health conditions? YOU & PERSONAL TRAININGTell us about some of your hopes and expectations from your wellness coach: RECORD SHEETCurrent Weight Target Weight Diet Recall(Ideally for Last 3 Days)
