Toll Free: 1.888.269.1TOS(867)

Trainers on Site First Step Pre-Screening & Assessment Form

Name:
Phone Number:
Email Address:
Address:
City:
Province:
Postal Code:
Current Exercise Equipment:

Personal Fitness Goals

What is your health and/or fitness related goals?  
Please list in order or priority, please be as specific as possible.                
Ex. (Lose 20 Lbs.)    Time Frame (In 4 Months)
1. Time Frame
2. Time Frame
3. Time Frame
Describe why you want to achieve the goals above. (Examples: More confidence, increased energy, feel 10 years younger, able to fit in old clothes again etc.)

Current Lifestyle & Fitness Status

  1. I would rate my current physical fitness level as.
    Sedentary Somewhat Active Active Athletic
  2. I would rate my current health status as.
    Unhealthy Somewhat Healthy Healthy Optimal Health
  3. Physical activity is important to me.
    Not important Somewhat Important Important Extremely important
  4. I enjoy exercising and living an active lifestyle.
    I Don’t Somewhat Enjoy Enjoy Extremely Enjoy
  5. I believe that exercise can help me succeed in achieving my health and fitness goals.
    Disagree Somewhat Disagree Agree Strongly Agree
  6. Do you have any injuries or conditions that may affect your ability to perform physical activity?
    Yes No
    If YES please list
  7. Have you ever participated in a structured fitness program before?
    Yes No
    IF YES, when was this and what results did you achieve?
  8. Have you ever used a personal trainer before?
    Yes No
    IF YES, when was this and what results did you achieve?
  9. Are you currently enrolled in an exercise program that has at least 30 to 60 minutes of moderate activity 4 – 7 days per week?( Examples: weight training, jogging, fitness classes etc.)
    Yes No
    IF YES, when was this and what results did you achieve?
  10. When were you in the best shape of your life? How did you feel?

Dietary Habits

  1. I would rate my current eating habits as.
    Very Poor Poor Moderate Good Excellent
  2. I would rate my self-discipline with regards to eating.
    Uncontrolled Controlled Disciplined Very disciplined
  3. I feel comfortable changing my food intake and choices to meet my health and fitness goals.
    Uncomfortable Somewhat Comfortable Comfortable Very Comfortable
  4. I am serious about achieving my optimal nutritional goals.
    Not Serious Somewhat Serious Serious Very Serious

Nutritional Supplementation

  1. Do you currently take any nutritional supplements? Example: Multi-Vitamin, Protein powder?
    Yes No
    IF YES please list?
  2. Have you taken nutritional supplements in the past?
    Yes No
    IF YES please list?
  3. Are you willing to incorporate nutritional supplements into your training program as long as they are safe and effective?
    Not Willing Somewhat Willing Willing Very Willing

How did you hear about Trainers On Site?

Fitness Source
T.V appearance
Internet / Google search
Print Ad
Newspaper article, blog
Friend recommendation
Car
Tradeshow
Radio

Toll Free:1.888.269.1TOS(867) or E-mail: info@trainersonsite.com