| Eating for fuel is a life long journey, not an overnight trip. Like any road you travel, expect bumps, red lights, yellow lights, detours and potholes. |
| Exercise use to go by another name- It was called SURVIVAL. |
| All major Credit Cards accepted |
| Fitness Lifestyles Weight Training, Cardio, & Nutrition Questionnaire Attention: This Questionnaire does not have to be filled out if you are considering hiring me as a one on one trainer. The following questionnaire may be cut copied and pasted to your email and emailed to me at Muscledude@cinci.rr.com or may be printed and mailed in care of : Rob Quimby Fitness Lifestyle personal Training 8880 Walnut Street West Chester, Ohio 45069 On-line Credit card payments are accepted through Pay Pal or Please send a Certified check or money order payable to Rob Quimby at the address listed above. Specify which program you wish to buy Cost of Fitness Program $93.00 ( Includes Workout, Cardio, Nutrition, and Supplementation) Cost of Single Workout Program $58.00 Cost of Single Nutritional and Supplement Program $58.00 Please no Vegetarian diet requests. All Sales are Final Absolutely No Refunds. So be sure you are serious. ----------------------------------------------------------------------------- I will process your questionnaire and send your personalized program as soon as I have received payment. Although questionnaires are generally processed immediately following payment, please allow one to two weeks for delivery as processing time is dependant on the complexity of information received. Disclaimer: Fitness Lifestyle Personal Training Services is not responsible for any injury or harm incurred by following an unsupervised program. Please consult a physician before beginning any strenuous exercise program. -------------------------------------------------------------------------------- -- Please complete the following contact information: (The information entered will remain in strict confidence and WILL NOT be given out for any reason!) First Name: Last Name: e-mail: Address: City: State: Zip Code: Home Phone: Bus. Phone: -------------------------------------------------------------------------------- -- Please complete the following general information: Occupation: Height: Male: Female: Date of Birth: Current Weight: Desired Weight: Current Body Fat % Desired Body Fat% -------------------------------------------------------------------------------- Bone Structure: Small Medium Large -------------------------------------------------------------------------------- Activity Level: Very Low Low Medium High Very High -------------------------------------------------------------------------------- Do you smoke? No: Yes: If Yes, Packs/Day: -------------------------------------------------------------------------------- Do you drink alcohol? No: Yes: If Yes, What is your consumption? Beer: oz/week Wine: oz/week Liquor: oz/week -------------------------------------------------------------------------------- Please indicate your fitness goals: Increase Muscle lose fat Reduce Fat level Tone Up Increase Energy Other (Please provide as much detail as possible) -------------------------------------------------------------------------------- In order for me to design a personalized program for you, please answer the following questions to the best of your ability. Beginner Beginner/Intermediate Intermediate Advanced -------------------------------------------------------------------------------- 1. Are you a student attending school? No Yes If Yes, please indicate if you are attending: High School College Other -------------------------------------------------------------------------------- 2. Do you participate in sports? No Yes If Yes, please indicate type of sports: (Please provide as much detail as possible) -------------------------------------------------------------------------------- 3. Have you ever trained with weights? No Yes If Yes, please indicate your training experience: Beginner Intermediate Advanced -------------------------------------------------------------------------------- 4. Do you have any past or current medical problems that include but are not limited to: diabetes, asthma, epilepsy, heart disease, high blood pressure, etc.)? No Yes If Yes, please explain: (Please provide as much detail as possible) Enter date of last physical: -------------------------------------------------------------------------------- 5. Do you have any joint problems (double jointed, lack of range of motion, "trick knee", etc.)? No Yes If Yes, please explain: (Please provide as much detail as possible) -------------------------------------------------------------------------------- 6. Have you had any operations in the last two years? No Yes If Yes, please explain: (Please provide as much detail as possible) -------------------------------------------------------------------------------- 7. Are you currently taking any medication? No Yes If Yes, please explain: (Please provide as much detail as possible) -------------------------------------------------------------------------------- -- The following questions pertain to your current weight training activities. 8. Where do you plan to weight train? Gym Home Other: -------------------------------------------------------------------------------- 9. Do you have a training partner? No Yes -------------------------------------------------------------------------------- 10. What kind of weights do you prefer? Free Weights Machines -------------------------------------------------------------------------------- 11. Which days of the week would you like to weight train? Monday Tuesday Wednesday Thursday Friday Saturday Sunday -------------------------------------------------------------------------------- 12. How long would you like each weight training session to be? 30 mins. 45 mins. 60 mins. Other: -------------------------------------------------------------------------------- 13. Please indicate the names and types of weight training equipment available to you (including starting weights and weight increments): (Please provide as much detail as possible) -------------------------------------------------------------------------------- 14. Please provide your current weight training log information (including weights, sets, reps, days per week, name of exercise and on which days): (Please provide as much detail as possible) -------------------------------------------------------------------------------- -- The following questions pertain to your current level of aerobic/cardiovascular fitness. 15. Which days of the week would you like to do cardiovascular training? Monday Tuesday Wednesday Thursday Friday Saturday Sunday -------------------------------------------------------------------------------- 16. How long would you like each cardiovascular training session to be? 30 mins. 45 mins. 60 mins. Other: -------------------------------------------------------------------------------- 17. What type of cardiovascular exercise do you prefer? Cycling Stepper Treadmill Running Other: -------------------------------------------------------------------------------- 18. Please indicate the names and types of cardiovascular training equipment available to you: (Please provide as much detail as possible) -------------------------------------------------------------------------------- 19. Please provide your current cardiovascular training log information (including days per week and on which days): (Please provide as much detail as possible) -------------------------------------------------------------------------------- -- The following questions pertain to your current dietary habits. 20. Have you tried "dieting" before? No Yes If Yes, What have you tried? (Please provide as much detail as possible) -------------------------------------------------------------------------------- 21. Are you allergic to any foods? No Yes If Yes, What are your food allergies? -------------------------------------------------------------------------------- 22. Do you have a lactose intolerance? No Yes -------------------------------------------------------------------------------- 23. Are there any foods you refuse to (or do not) eat? No Yes If Yes, please describe: -------------------------------------------------------------------------------- 24. Which of the following meals do you currently eat, and at what time do you eat them? Breakfast Time Morning Snack Time Lunch Time Afternoon Snack Time Dinner Time Evening Snack Time -------------------------------------------------------------------------------- 25. Do you eat a lot of protein (meat, fish, poultry, etc.)? No Yes -------------------------------------------------------------------------------- 26. Do you eat a lot of cabohydrates (pasta, rice, potatoes, fruits, breads, etc.)? No Yes 27. How many 8 oz. glasses of water (excludes soda, coffee, tea, etc.) do you drink each day? Enter Average per Day: -------------------------------------------------------------------------------- 28. How many meals per day would you feel comfortable eating? 4 5 6 7 29. Are you currently taking food Supplements? 30. How much per month can you spend on Supplements? -------------------------------------------------------------------------------- -- How did you hear about Fitness Lifestyle Personal Training Services: -------------------------------------------------------------------------------- -- Do you have any comments, questions, or concerns regarding the programs? -------------------------------------------------------------------------------- Disclaimer: Fitness Lifestyle Personal Training Services is not responsible for any injury or harm incurred by following an unsupervised program. Please consult a physician before beginning any strenuous exercise program. Site developed & maintained by Fitness Lifestyle Personal Training. |
| www.F.L.P.T.net |
All major Credit
Cards accepted
$7.00 added to all
sales.
Cards accepted
$7.00 added to all
sales.
| Email Rob |