Your Personal Training Package Questionnaire

Congratulations on making the life-changing decision to allow our team at Pacific Elite Fitness to guide you to optimum health, wellness, nutrition, fat-burning and lean muscle toning.

We will be completely customizing your entire program, but we must first have critical metabolism, health and lifestyle information. Please contact us if you have any questions.

When you complete this form, please remember to press the "Submit" button at the bottom of the page. A personal trainer will contact you within 48 hours after completing this form. Please e-mail elite@pacificfit.net with any questions.

Your Contact Details

Name: Age: Today's Date:

Primary e-mail address:

Primary Phone:

Mailing Address:

Your Lifestyle

1. Describe your job.

2. Do you consider your job physically challenging or active?

3. How many hours do you spend in front of a computer?

4. On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career.

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5. On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your personal life.

1 2 3 4 5 6 7 8 9 10

6. What time do you usually go to bed at night and wake up in the morning?

7. Are there any other notes about your lifestyle that you would like to share?

21 Important Questions About Your Health History

1. Do you suffer from back pain?

Yes  No  Details:  

2. Are you sensitive to touch/pressure in any area?

Yes  No  Details:  

3. Do you have tension, numbness or pain in a specific area?

Yes  No  Details:  

4. Do you experience frequent headaches?

Yes  No  Details:  

5. Are you pregnant?

Yes  No  Details:  

6. Have you ever given birth?

Yes  No  Details:  

7. Do you have high blood pressure?

Yes  No  Details:  

8. Do you have high cholesterol?

Yes  No  Details:  

9. Have you ever had surgery?

Yes  No  Details:  

10. Have you ever broken any bones?

Yes  No  Details:  

11. Do you experience stiff, swollen or painful joints?

Yes  No  Details:  

12. Do you have difficulty sleeping?

Yes  No  Details:  

13. Do you experience fatigue or lack of energy?

Yes  No  Details:  

14. Do you experience cold hands or feet?

Yes  No  Details:  

15. Have you ever been advised by a physician to avoid any type of exercise?

Yes  No  Details:  

16. Have you ever been knocked unconscious or suffered a concussion?

Yes  No  Details:  

17. Do you (or does someone in your family) have a cardiac condition?

Yes  No  Details:  

18. Do you have any known allergies?

Yes  No  Details:  

19. Are you currently taking any medications (not nutrition supplements)?

Yes  No  Details:  

20. Do you smoke or have you smoked in the past?

Yes  No  Details:  

21. Are there any medical issues which have not been discussed on previous questions?

Yes  No  Details:  

Your Exercise Status

1. Describe your current exercise routine, if any.

2. What is the heaviest you have weighed, and how old were you at that time?

3. What previous fat loss, lean muscle gain, or body improvement treatment(s) have you tried? Please state what and when.

4. Have you ever had any of the following: physical therapy, chiropractic, massage, acupuncture, Feldenkrais, rolfing, Alexander technique, Other? Please elaborate.

5. Have you ever worked with a personal trainer? If so, provide details:

6. How many days do you have to commit towards exercise (include the approximate number of minutes)?

7. Are there any areas of your body that you consider “problem areas”?

Your Nutrition & Metabolism

1. Have you ever had your metabolism tested?

Yes  No  Details:  

2. Do you count or track calories?

Yes  No  Details:  

3. Does a high carb snack or meal, with lots of veggies, bread, toast, cereals, rice, fruits, grains or potatoes as the main food source satisfy or stimulate your appetite?

1 2 3 4 5 6 7 8 9 10

satisfies                                                        stimulates

4. Do you notice that you gain a lot of weight when you eat red meat, or lose weight?Do you look slimmer in the mirror or do your clothes fit easier?

1 2 3 4 5 6 7 8 9 10

gain weight                                                   lose weight

5. Do you constantly look forward to the next meal, frequently thinking about foods and what you want to eat?

1 2 3 4 5 6 7 8 9 10

yes                                                                  no

6. What is your appetite like at:

Breakfast?

1 2 3 4 5 6 7 8 9 10

weaker                                                          stronger

Lunch?

1 2 3 4 5 6 7 8 9 10

weaker                                                           stronger

Dinner?

1 2 3 4 5 6 7 8 9 10

weaker                                                           stronger

7. Do higher fat foods and/or higher protein foods such as dark meats, avocados, cream, butter, or coconuts within 1-2 hours of bedtime help you sleep better?

1 2 3 4 5 6 7 8 9 10

yes                                                           no

8. If you ate a large salad with some low-fat meat like chicken breast for lunch (versus a higher fat meat like a hamburger patty), how would it affect your productivity the rest of the afternoon? What about if you ate a steak?

Salad:

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Energetic & satisfied                                 Tired & hungry

Steak:

1 2 3 4 5 6 7 8 9 10

Energetic & satisfied                                 Tired & hungry

9. How often do you typically feel the need to eat on an average day? One meal would be a 1, three meals a day would be a 5, while six to seven meals a day would be a 10.

1 2 3 4 5 6 7 8 9 10

1-2x including snacks                                  6-7x including snacks

10. How much do you enjoy sour foods like pickles, sauerkraut, or vinegar?

1 2 3 4 5 6 7 8 9 10

love them                                                   can’t stand them

11. At Thanksgiving or a meal where you eat turkey, assuming all the turkey is moist, if you prefer white meat give yourself a 1, dark meat a 10, and no preference a 5.

1 2 3 4 5 6 7 8 9 10

white meat                                                    dark meat

12. What is a typical breakfast?

13. Lunch?

14. Dinner?

15. Describe your snacking habits in between breakfast, lunch, and dinner:

16. Describe your pre-workout nutritional habits, if any:

17. Describe your “during the workout” nutritional habits, if any:

18. Describe your post-workout or nutritional habits, if any:

19. Describe all nutritional supplements you are currently using. Include multi-vitamins, sport supplements, electrolytes, and any special juices, pills, capsules or tablets:

20. How much water do you drink per day, apart from exercise?

21. How much water do you drink during exercise?

22. Please describe any known food sensitivities, or intense likes/dislikes:

23. Do you ever have heartburn, gastrointestinal distress, or stomach problems?

24. Please describe any religious, ethical, or logistical limitations regarding nutrition (include information about any current nutritional sponsors):

25. Use the following section to include any additional nutritional notes:

Your Final Thoughts

Describe what you truly desire from completing this program. What do you truly desire? Out of your fitness? Out of life? What do you want your body to look like in 1 year? 5 years? In other words, why are you sitting here, taking valuable minutes out of your life to complete this form? What are your specific goals or objectives? Be as honest and specific as possible, describing your dream body, lifestyle, or health. Pour yourself onto the page. Include anything that you feel would be helpful that you haven’t yet had a chance to express. All your responses remain completely confidential!

 Please read the following waiver, then, if you agree to the terms, sign your name. Activity: Any and all prescribed, instructed, implied or suggested activities from Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield (collectively referred to as “The Released Party”), and all volunteers, agents, employees or independent contractors in any way associated with the Released Party, including, but not limited toall multi-sport related physical activities, outdoor endurance running and sprinting, running, jogging, and walking at a moderate to high effort on a grass surface; muscular stretching and flexibility exercises; body weight and calisthenic exercises, including push-ups, sit-ups, squats and lunges; plyometric and jumping activities including straight up and side to side jumping on surface such as rubber, grass, and asphalt; suggested take home exercises; open water swimming (for triathletes and swim lessons), often at depths above head level; weightlifting; rowing; stairclimbing; indoor bicycling; bicycling on and off roads that are open to traffic; dismounting from bicycle; tracking nutritional intake; increasing or decreasing caloric intake; suggested meal plans, menus, or recipes; food supplementation; or any other activity prescribed, instructed or suggested from Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield and not listed in this document. RELEASE OF CLAIMS, ASSUMPTION OF RISK, CONTACT AND WAIVER OF LIABILITY I understand and am aware that this Activity is potentially hazardous. I acknowledge the possibility that injuries and physical and mental changes arising during and/or resulting from engaging in this Activity do exist. These injuries and changes include, but are not limited to, abnormal blood pressure, fainting, disorders in heartbeat, heart attack, joint injuries, and, in some instances, death. I understand Injuries and Changes could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life. I am voluntarily participating in this Activity with knowledge of the dangers involved. I understand and take sole responsibility for any and all Injuries and Changes that may occur to myself and/or others, including but not limited to Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield, related to any and all Activities associated with Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield, even if not specifically set forth in this document, whether or not they fall within the scope of reasonably foreseeable injuries related to this Activity, and whether or not undertaken in the presence of staff or physical location of Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield. Although Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield will take precautions to ensure my safety, I expressly assume and accept sole responsibility for my safety and for any and all Injuries and Changes that may occur. 
I release Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield and all volunteers, agents, employees or independent contractors in any way associated with the Released Party from any and all liability for any personal injury, death, property damage or loss I may suffer as a result of, arising from, related to or in any way connected to my participation in this Activity, and for any cause whatsoever including negligence, including active negligence, passive negligence or gross negligence on the part of Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield and all volunteers, agents, employees or independent contractors in any way associated with the Released Party I declare myself physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in this Activity. I acknowledge I have been informed of the need for a physician’s approval for my participation in an exercise/fitness Activity. I recognize it is my sole responsibility to obtain an examination by a physician prior to involvement in any exercise program. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this Activity, I acknowledge I am doing so at my own risk. I understand that if under any circumstances I experience lightheadedness, dizziness, muscular pain, excessive fatigue or any other painful or uncomfortable signs that exceed normal exercise fatigue, I am not obligated to continue this Activity. Furthermore, I may stop this Activity at any time as I desire. Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield’s personal trainers, coaches, and sports nutritionists are not Physicians or Registered Dieticians. They do not diagnose or treat disease. I have been informed that I should consult a Physician before undergoing any dietary or food supplement changes. Any recommendations or suggestions from Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield for changes in my diet, including but not limited to the use of food supplements, food substitutions, caloric intake, meal plans, recipes, and menus are entirely my responsibility, and I release Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield from any and all liability for any illness, personal injury, death, property damage or loss I may suffer as a result of any change in my nutrition, diet, or food intake. I acknowledge and agree no warranties or representations have been made to me regarding the results I will achieve from this program. I understand results are individual and may vary. This Waiver and Release shall be governed by the laws of the State of Washington. All disputes arising from this Waiver and Release Agreement, and participation in any Activity, whether in Contract, Tort or Equity, shall be brought in the State of Washington By signing below, you agreed to subject yourself to the jurisdiction of Washington and thereby waive any argument of lack of personal jurisdiction or forum non conveniens. I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield, its respective representatives, executors, and/or assigns. I confirm that I have read over this agreement before signing, that I understand it, and that it will be binding not only on me but also on my heirs, my next of kin, my executors, administrators and assigns. I represent and warrant I am signing this agreement freely and willfully and not under fraud or duress. I further represent and warrant no social relationship exists between Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield and me, or if such a social relationship exists, for purposes of my training sessions, Trainer and I have assumed a strict business relationship, and I understand any social relationship does not render this waiver invalid. These exculpatory clauses are intended to apply to any and all activities occurring during the time for which I have contracted with Human Wellness Solutions, Pacific Elite Fitness or Ben Greenfield.

I have completely read, fully understand, and agree to this release of claims and waiver of liability. I also understand that any nutritional recommendations from Pacific Elite Fitness or Ben Greenfield are merely a suggestion and not a prescription:

Please type full name here: