Personal Information

Full Name*

Occupation

Address

Street Address

Street Line 2

City

State

Zip Code

Email Address*

Phone (Home)*

Enter as (XXX) XXX-XXXX

Phone (Work)*

Enter as (XXX) XXX-XXXX

Phone (Cell)*

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Fax

Date of Birth

Age

Please enter a value between 13 and 100.

Emergency Contact*

Relationship*

Contact's Phone*

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Physician's Name

Physician's Address

Street Address

Street Line 2

City

State

Zip Code

PAR-Q Form

Please mark YES or No to the following:

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
 Yes No

Do you frequently have pains in your chest when you perform physical activity?
 Yes No

Have you had chest pain when you were not doing physical activity?
 Yes No

Do you lose your balance due to dizziness or do you ever lose consciousness?
 Yes No

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.)?
 Yes No

Are you pregnant now or have given birth within the last 6 months?
 Yes No

Have you had a recent surgery?
 Yes No

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?
 Yes No

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?
 Yes No

Do you drink alcohol?
 Yes No

If "Yes", how many glasses?

How many hours do you regularly sleep at night?

Level of Activity at Your Job
---SedentaryActivePhysically Demanding

Does your job require travel?
 Yes No

On a scale of 1-10, how would you rate your stress level?
Please enter a value between 1 and 10.

(1=very low 10=very high)

List your 3 biggest sources of stress

Is anyone in your family overweight?
Mother Father Sibling Grandparent 

Were you overweight as a child?
If "yes", at what age?

Fitness History

When were you in the best shape of your life?

Have you been exercising consistently for the past 3 months?
 Yes No

When did you first start thinking about getting in shape?

What if anything stopped you in the past?

On a scale of 1-10, how would you rate your present fitness level?
Please enter a value between 1 and 10.

(1=Worst 10=Best)

Nutrition Related Questions

On a scale of 1-10, how would you rate your Nutrition?
Please enter a value between 1 and 10.

(1=very poor 10=excellent)

How many times a day do you usually eat (including snacks)?

Do you skip meals?
 Yes No

Do you eat breakfast?
 Yes No

Do you eat late at night?
 Never Sometimes Often

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 so, why?

Do you know how many calories you eat per day?
 Yes No

If "Yes", how many?

Are you currently or have you ever taken a multivitamin or any other food supplements?
 Yes No

If "Yes", please list the supplements.

At work or school, do you usually...
 Eat out Bring lunch

How many times per week do you eat out?

Do you do your own grocery shopping?
 Yes No

Do you do your own cooking?
 Yes No

Besides hunger, what other reason(s) do you eat?
 Boredom Social Stressed Tired Happy Nervous

Do you eat past the point of fullness?
 Never Sometimes Often

Do you eat foods high in fat and sugar?
 Never Sometimes Often

List 3 areas of your nutrition you would like to improve:

How often do you take part in physical exercise?
---5-7 times a week3-4 times a week1-2 times a week

If your participation is lower than you would like it to be, what are the reasons?
 Lack of Interest Illness/Injury Lack of Time Other

How long have you been consistently physically active for?

What activities are you presently involved in?
Include Activity, Frequency, Average Length, and Difficulty

If you could design your own exercise program, what would an ideal training week look like to you? Please be specific. List your favorite activities, rest days, time spent etc.
Include desired schedule for each day of the week.

Goal Setting

How can a Personal Trainer help you? Please check all that apply.
 Lose Body Fat Nutrition Education Develop Muscle Tone Rehabilitate an Injury Start an Exercise Program Design a more advanced program Safety Sports Specific Training Increase Muscle Size Fun Motivation Other

In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure all your goals are 'SMART'.

S= Specific (Provide details, how long, how much etc.)
M= Measurable (How will you measure whether you’ve reached your goals)
A= Attainable (Be realistic, set smaller goals)
R = Rewards-Based (Attach a reward to each goal)
T = Time Frame (Set specific dates for goals)

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

How will you feel once you've achieved these goals? Be specific.

Where do you rate health in your life?
 Low Priority Medium Priority High Priority

How committed are you to achieving your fitness goals?
 Very Somewhat Not Very

What do you think the most important thing your Personal Trainer 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 etc.).

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

Miscellaneous Questions

How did you hear about us?
 Brochure Word of Mouth Yellow Pages Website Other

If you were referred to us, who told you about our services?

Why did you choose to train with North Point Personal Training instead of another organization?
 Location Personal Trainers Cost Customer Service Word of Mouth Programs

How far do you live from our training studio? (in miles)

Which newspaper(s) or local magazines do you read?

Which radio station(s) do you listen to?

Which local morning TV show do you watch?

What would cause you to discontinue training with North Point Personal Training?

Participant Release and Knowledge of Agreement

1.) I wish to participate in the exercise and training program offered by North Point Personal Training. I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. I agree that North Point Personal Training and/or Good Bodies Inc. 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 North Point Personal Training and Good Bodies Inc., 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.

2.) 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 on going, which might affect my ability to exercise safely and with minimal risk of injury.

3.) 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 lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer

4.) 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.

5.) I understand that North Point Personal Training bills its Personal Training clients on a pre-pay basis. Once my trainer and I have decided upon the type of training package and payment plan I will purchase, payment must be made before the sessions are conducted. Credit cards, cash and checks made payable to North Point Personal Training are all accepted. I understand that all Personal Training sessions are non-refundable.

6.) I understand that North Point Personal Training operates on a scheduled appointment basis for all Private Training sessions and thus, requires that I provide 24 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given. Should I cancel a session without 24 hours prior notice, I will be charged in full for that session. I understand that North Point Personal Training recommends that all cancelled sessions be rescheduled to ensure consistency and fitness progress.

7.) I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by my Personal Trainer. I understand that North Point Personal Training photographs many of their client events/sessions and I provide written approval for them to use these pictures for promotional purposes.

By clicking the "Submit" button below, I agree that 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.