Hoboken Boot Camp and Personal Training

Please complete the following form. Mark will contact you within 48
hours to follow up with you and discuss your health and fitness assessment.


General Information
Name
    
Age
    
Gender
    
Address
    
City
    
Zip
    
State
    
Day Phone
    
Evening Phone
Email Address
   
Cell Phone
Doctors Name
   
Phone
Emergency Contact
    
Phone

Class Dates
Requested

Time:

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.  If you recently had surgery will you consult your physician prior to increasing your physical activity?      If yes, please explain
10.  Epilepsy?   If yes, please explain
11.  Angina?   If yes, please explain
12.  High Blood Pressure?   If yes, please explain
13.  Knee Problems?   If yes, please explain
14.  Shoulder Problems?   If yes, please explain
15.  Back Problems?   Cervical / Thoracic / Lumbar?
16.  Has a doctor ever said you have heart trouble?   If yes, please explain
17.  Do you often feel faint or have spells of severe dizziness?    If yes, please explain
18.  Do frequently suffer from pains in your chest   If yes, please explain
19.  Has a doctor ever told you that your blood pressure was too high   If yes, please explain
20.  Do You have any bone or joint problems   If yes, please explain
21. Is there a good physical reason not mentioned here why you should not follow an activity program?    If yes, please explain
22.  Are you currently taking any type of medication?   If yes, please explain
23.  Have you consulted a Physician regarding increasing your physical activity and/or having a fitness evaluation?   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?
What is your current weight?
Years at present weight:
What has been your highest/lowest weight as an adult?
How tall are you?
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? 
How often do you consume alcohol?
Do you smoke cigarettes? If yes how much?
Do you drink coffee? 
How often do you drink soda?
How much water do you drink a day? 
 

 

 
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