Health, Wellness and Lifestyle Questionnaire
Name: _________________________________________________
Date: ______________________
Address: _______________________________________________
Birthday: ____________________
________________________________________________
Age: ________Sex: M F
Home Phone: ________________________________ Cell Phone: ____________________________________
Occupation:_______________________________________________________________________________
Email Address: _____________________________________________________________________________
Emergency Contact: Name: __________________________________ Phone: __________________________
How did you hear about us? _______________________ (Word of Mouth, Friend, Newsletter, Website, other)
If you are under 18, what are your parent’s names and contact info:
Mom: _______________________________________________ Phone: _______________________________
Dad: ________________________________________________ Phone:________________________________
The following information is required to assess your physical fitness level and to establish your exercise prescription.
Your health questionnaire and test results are confidential and will not be released to anyone other than yourself.
Do you have any medical conditions or symptoms that could prevent you from participating in any exercise regimen,
training, or routine?
If yes, please list all: ________________________________________________________________________________
Have you consulted with your physician about starting an exercise program?___________________________________
In the last 6 months, have you experienced any of the following:
Localized muscle soreness Y N
Joint Stiffness Y N
Flare-up of old injuries Y N
Loss of local muscle strength Y N
Noticeable loss of muscle size Y N
Restricted joint movement Y N
Do you take any medication on a regular basis? Y N Prescription and/or Non-Prescription
If yes, please list:___________________________________________________________________________________
Please note any surgeries or injuries (past or present)
__________________________________________________________________________________________________
Nutrition
On a scale of 1 to 10 (1 is low, 10 is high), how important is your diet on a daily basis?_____________________________
Explanation ________________________________________________________________________________________
Please describe one typical day of eating. Please write down everything you eat and drink and the amount.
Time_______Breakfast ______________________________________________________________________________
Time_______Snack _________________________________________________________________________________
Time_______Lunch _________________________________________________________________________________
Time_______Snack__________________________________________________________________________________
Time_______Dinner _________________________________________________________________________________
Estimated number of glasses of water consumed each day __________ Sodas:_________________________
Do you currently, or have you in the past, suffer(ed) from an eating disorder? Y N
If yes, please explain. ________________________________________________________________________________
Please list your current participation in physical activities:
What activities do you currently participate in? ___________________________________________________
Times-Per- Week Minutes/Session? _____________________________________________________________
What usually interrupts your workout program? __________________________________________________
How long do you usually stick with a workout program? ____________________________________________
If you stop working out for an extended period of time, why? ________________________________________
How many hours of sleep do you average per night? ________
Please rate your current life stress level: (1-10; 10 is the highest stress level)
Rating: _______ Why do you feel it’s this high? _____________________________________________
Please circle your current fitness goals and rate your top three in order, 1 being the most important and a 3 being the
least importance.
General Health
Weight Loss/Gain
Strength Training
(lower cholesterol, blood pressure, body fat, etc)
Special Occasion
Pain Management
Appearance/Body Parts
(wedding, anniversary, vacation, etc)
Job Performance
Sports Performance
How much time can you devote to your workout program?
Days/Week:
2
3
4
Minutes/Day:
What areas of exercise interest you? Cardio
30min
Strength
45min
60min
Plyometric
Functional
Sport
LIABILITY WAIVER
The undersigned recognizes that the use of 401 Fitness services involve an inherent risk of physical injury
including that caused by the negligence of the undersigned, Chad Vogel, Diana Rodriguez, 401 Fitness, or
contractors and employees of 401 Fitness. The undersigned hereby agrees to assume the risk of injury in its
entirety regardless of the cause. Chad Vogel, Diana Rodriguez, 401 Fitness, and all contractors and
employees of 401 Fitness shall not be liable for injuries or damages to the undersigned, or the property of
the undersigned, or by subject to any claim, demand, injury, death, or damages whatever, including,
without limitation, those damages resulting from acts of active or passive negligence on the part of Chad
Vogel, Diana Rodriguez, 401 Fitness, and all contractors and employees of 401 Fitness for all such claims,
demands, injuries, death, damages, actions, or causes of action. It is specifically agreed that Chad Vogel,
Diana Rodriguez, 401 Fitness, and all contractors and employees of 401 Fitness shall not be responsible or
liable to the undersigned for articles lost or stolen in connection with Chad Vogel, Diana Rodriguez, 401
Fitness, or contractors and employees of 401 Fitness’s service.
Print Name: __________________________________________________
Signature: ___________________________________________________
Date: _______________________________________________________
If you are under 18 years of age, please have parents sign here:
Print Name: ___________________________________________________
Parent’s Printed Name: __________________________________________
Parent’s Signature: ______________________________________________
Date: _________________________________________________________
Cancellation Policy: To give our 401 Fitness staff advance notice we do require that you give
us 24 hours’ notice for any appointments that need to be cancelled to insure that you will
not be charged. Thank you!!