Body Solutions Fitness
Successful solutions that meet your fitness expecations

On-Line Registration

ON-LINE REGISTRATION AND FITBASE ASSESSMENT
First Name:
Last Name:
Date of Birth:  
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Cell Phone:
Home Phone:
Email:
Emergency Contact:  
Emergeny Contact Phone:  
Family Doctor's Name:  
Family Doctor's Phone:  
 
HEALTH HISTORY


Please answer yes or no to the following. If you answer YES to any of the following questions, please elaborate.
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?  
Do you frequently have pains in your chest when you perform physical activity?  
Have you had chest pain when you were not doing physical activity?  
Do you lose your balance due to dizziness or do you ever lose consciousness?  
Do you have a bone, joint or any other health problem that causes you pain or limitys that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsey, respiratory ailments, back problems, etc.)?  
Are you pregnant now or have given birth within the last 6 months?  
Have you had a recent surgery? (Within 12 months)  
Do you take any medications, either prescription or non-prescription, on a regular basis? If so, what is the medication for?  
How does this medication affect your ability to exercise or achieve your fitness goals?  
Is anyone in your family overweight?:
 
LIFESTYLE RELATED QUESTIONS
 
Do you smoke? If so, how many?  
Do you drink alcohol? If es, how many glasses per week?  
How many hours do you regularly sleep at night?  
Is your job sedentary, active, or physically demanding?
Does your job require travel?  
On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?
List yeour 3 biggest sources of stress:  
Is anyone in your family overweight?  
Were you overweight as a child? If yes, at what age(s)?  
   
FITNESS HISTORY
When were you in the best shape of your life?  
Have you been exercising consistently for the past 3 months?  
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 (1=worst 10=best?  
   
NUTRITION RELATED QUESTIONS
On a scale of 1-10, how would you rate you nutrition (1= very poor 10=excellent)?:  
How many times a day do you usually eat (including snacks)?  
Do you skip meals?  
Do you eat breakfast?  
Do you eat late at night? Sometimes-Often-Never:  
What activities do you engage in while eating? (TV, reading, ect):  
How many glasses of water do you consume daily?  
Do you feel drops of energy levels throughout the day? If so, what time of day?  
Do you know how many calories you eat per day? If yes, how many?  
Are you currently or have you ever taken a multivatamin or any other food suppliments? If yes, what suppliments?  
At work or school, do you usually eat out or bring food?  
How many times per week do you eat out?  
Do you do your own cooking?  
Besides hunger, wat other reason(s) do you eat? Please choose any choice that applies: Boredom-Social-Stress-Tired-Depression-Happy-Nervous:  
Do you eat past the point of fullness?  
Do you eat foods high in fat and sugar?  
List 3 areas of your nutrition you would like to improve?
   
EXERCISE RELATED QUESTIONS
Skip to the next section if you are presently inactive.
How often do you take part in physical exercise? Choose from the following: 5-7x/week - 3-4x/week - 1-2x/week:  
If your participation is lower than you would like it to be, what are the reasons?  
How long have you been consistently physically active for?  
What fitness activities do you presently perform?  
   
GOAL SETTING
How can a Fitness Trainer help you? Please list the choices that apply to you: Lose Body Fat-Develop Muscle Tone-Rehabilitate an Injury-Nutrition-Education-Start an Exercise Program-Safety-Sports Specific Training-Fun-Motivation-Other:
Please list in order of priority, the 3 fitness goals you would like to achieve in the next 10 weeks to 1 year:
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 - Simi - Not Very:  
What do you think the most important thing your Fitness Trainer and/or Fitness Class can do to help you achieve you fitness goals?  
What do you feel are the obsacles or potential actions, behaviors or activities that could impede your progress towards accomplishing your goals?  
Outline 3 methods that you plan to use to overcome these obstacles:  
   
MISCELLANEOUS QUESTIONS
How did you hear about us?  
If you were referred to us, who told you about our services?  
Why did you choose to workout with Body Solutions Fitness instead of another organization?  
How far do you live from our fitness/perfermance center?  
Which newspaper(s) do you read?  
Which radio station(s) do you listen to?  
Which local Magazine(s) do you read?  
What would cause you to discontinue training with Body Solutions Fitness?  

 The Gift of Fitness:
 
At Body Solutions Fitness, we rely on happy clients telling others about our services. We may both be able to make a huge difference in somebody's life. Please take the time to list the names of 2 friends who you would like to offer a complimentary consultation to or invite to class. Once you discuss this with them, we'll call them and book them for a trial workout.  


 CLASS TIMES:
Class Times are as follows::

Mondays, Tuesdays, Thursdays, Fridays @ 5:00 AM to 6:00 AM 

Mondays, Tuesdays, Thursdays, Fridays @ 6:00 AM to 7:00 AM

Mondays, Tuesdays, Wednesdays, Thursdays @ 5:30-6:30 PM

Mondays, Tuesdays, Wednesdays, Thursdays @ 7:30-8:30 PM

You may come to a combination of days and times in order to get your four workouts in per week. I do want you to list which class you will consider your primary time.
The submission of the on-line registration form pre-registers you for class. By doing so, you agree to pay for the class amount of $280.00 prior to the end of the first class in the new term. Please acknowledge by typing your name in the text box to the right.
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