Lifetime fitness center’s weight loss wars application form

Download 50.96 Kb.
Date conversion21.10.2017
Size50.96 Kb.







812 Elm Avenue

Story City, IA 50248

Contact: Chris Peters

(515) 733-4029

Assessing Your Needs:

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to develop a program that addresses your needs, goals and interests and is safe and effective.

Name: ________________________ Date of Birth ___/___/___ Age: _____

Address: _______________________________________________________

Street (Apt. #) City State Zip Code
Phone: _____________ (work) ______________ (home) ______________ (cell)
E-mail Address: _________________________ Height: ______Weight ______
Occupation: _____________________
Physician’s Name: ___________________ Physician’s Phone: _________________

Physician’s Address: __________________________________________________

Street City State Zip Code

Lifetime Fitness Center will send information regarding your physical exercise program to your physician and request medical clearance and/or restrictions on your behalf, unless you request otherwise.

Please check all that apply to you:
☻ Why do you want to participate in “WEIGHT LOSS WARS”? Attach additional sheets if necessary








☻ How did you hear about us?
ٱ Facebook ٱ Word of mouth ٱ Media ٱ Newsletter ٱ Website

Other ____________________


Please mark YES or NO to the following: YES NO

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 bone, joint, or any other health problem that causes you pain or

limitations that must be addressed when developing an exercise program

[i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, back problems, arthritis, anorexia bulimia, anemia, epilepsy, respiratory ailments (asthma, bronchitis, COPD), etc?] ___ ___

Are you pregnant now or have given birth within the last 6 months? ___ ___
Have you recently had surgery? ___ ___

If you marked YES to the previous question, please elaborate below:



Do you take any medications, either prescription or non-prescription on a

regular basis? ___ ___

If YES, what is the medication(s) & it’s(their) purpose:



How does this medication affect your ability to exercise? :


Lifestyle Related Questions: please circle or mark correct answer
1) Do you smoke? YES NO If YES, how many? ____ (day)
2) Do you drink alcohol? YES NO If YES, how many drinks per week? ____
3) How many hours of sleep do you average each night? ____
4) Describe your job: ٱ Sedentary ٱ Active ٱ Physically demanding
5) Does your job require you to travel? YES NO
6) On a scale of 1-10, how would you rate your stress level? (1= very low/10= very high) ____
7) List your 3 biggest sources of stress: a) __________ b) __________ c) __________
8) Is anyone in your family overweight? ٱ Mother ٱ Father ٱ Sibling ٱ Grandparent
9) Were you overweight as a child? YES NO

Exercise Related Questions: skip to next section if you are currently inactive.

1) How often do you take part in physical exercise? 5-7x/week 3-4x/week 1-2x/week never

2) If your participation is lower than you would like it to be, what are the reasons?

Lack of Interest Illness Injury Lack of Time Other _________________________ ___________________________________________________________________________________

3) How long have you been consistently physically active for? __________

4) What activities are you presently involved in?

Cardio &/or Sports Frequency/Week Average Length Easy/Med/Hard

_______________ _____________ _____________ _____________

_______________ _____________ _____________ _____________

_______________ _____________ _____________ _____________

Strength Training Frequency/Week Average Length Easy/Med/Hard

_______________ _____________ _____________ ______________

List of Exercises: __________________________________________________________


Stretching Frequency/Week Average Length

_____________ _____________

Developing Your Fitness Program:

1) Please mark how you prefer to exercise:

a) ٱ Inside ٱ Outside ٱ Combination

b) ٱ Large Groups ٱ Small Groups ٱ Alone ٱ Combination

c) ٱ Morning ٱ Afternoons ٱ Evenings ٱ Weekends
2) Realistically, how many times a week would you like to exercise? ____ x/week
3) Realistically, how much time would you like to spend during each exercise session? ____ minutes
4) What are the best days during the week for you to commit to your exercise program?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

5) If you could design your own exercise program, what would an ideal training week look like to you? Please be specific—INCLUDE DAYS, TIMES AND DURATION.








Goal Setting:
In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure that all of your goals are ‘SMART’.
S = Specific (Provide details, how long, how much etc.)

M = Measurable (How will you measure whether you’ve reached your goals)

A = Attainable (Be realistic, set smaller goals)

R = Rewards-Based (Attach a reward to each goal)

T = Time Frame (Set specific dated for goals)
1) Please list in order of priority, the fitness goals you would like to achieve within the next 3-12 months:

a) ___________________________________________________________________________ b) ___________________________________________________________________________ c) ___________________________________________________________________________

2) How will you feel once you’ve achieved these goals? Be specific:


3) Where do you rate health in your life? ٱ Low priority ٱ Medium priority ٱ High priority
4) How committed are you to achieving your fitness goals? ٱ Very ٱ Moderately ٱ Not very
5) What do you think the most important thing(s) Lifetime Fitness Center can do to help you achieve your fitness goals?



6) What obstacles do you think could prevent you from achieving your fitness goals (i.e. not training consistently, upcoming vacation, busy season at work, not sticking with the program, lack of time or motivation, other responsibilities etc.)?



7) Outline 3 methods that you plan to use to overcome these obstacles:

a) ________________________________________________________

b) ________________________________________________________

c) ________________________________________________________

Personal Contract

I (initials)____ promise to try to the best of my abilities to work toward my fitness goals, overcome obstacles to achieving my goals, and follow the advise of my Wellness Team.

Goals: a) ____________________ b) ____________________ c) ____________________
Rewards for meeting my goals: a) ________________ b) ________________ c) ________________

Client: __________________ LFC __________________

Participant Release and Knowledge of Agreement

  1. I, _______________________, wish to participate in the exercise and training program WEIGHT LOSS WARS offered by Lifetime Fitness Center. I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined and released by a physician of my choice if the situation warrants. I agree that Lifetime Fitness Center/Mary Greeley Medical Center, shall not be liable or responsible for any injuries to me resulting from my participation in the program (whether at home, outdoors, at the Lifetime Fitness Center, or at a corporate, commercial, residential, or other fitness facility) and I expressly release and discharge Lifetime Fitness Center/Mary Greeley Medical Center, it’s owners, employees, agents and/or assigns, from all claims, actions, judgments, and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This release shall be binding upon my heirs, executors, administrators and assigns.

I have read and understand this term: ________ (initial)

  1. I certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform my Wellness Team of any conditions or changes in my health, now and going on, which might affect my ability to exercise safely and with minimal risk of injury.

I have read and understand this term: ________ (initial)

  1. I understand my progress depends on my effort and cooperation in and outside of my exercise sessions at Lifetime Fitness Center. However, I understand that I am not obligated to perform nor participate in any difficult activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer/Wellness Team.

I have read and understand this term: ________ (initial)

  1. I understand that Lifetime Fitness Center operates on a scheduled appointment basis and thus, requires that I provide 12 hours notice when canceling an appointment. I understand that all cancelled sessions must be rescheduled as soon as possible to ensure consistency and fitness progress.

I have read and understand this term: ________ (initial)

  1. I understand that I will be required to track daily physical activity and nutrition and submit this information to my personal trainer on a regular basis. I have access to the internet, email, phone and/or texting for exercise and nutrition tracking and for staying in communication with my wellness team.

I have read and understand this term: ________ (initial)

  1. I consent to have before and after blood work done (at no cost to me) to better assess reductions in health risks attained through participation in WEIGHT LOSS WARS. Blood work will be provided by Mary Greeley Medical Center.

I have read and understand this term: ________ (initial)

  1. I consent to the use of my photo(s) and information about my progress being used in marketing material for the Lifetime Fitness Center. This information may be used in print publications as well as public websites.

I have read and understand this term: ________ (initial)

I have read this Release and Terms of agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.

___________________________ ____________________________

Client LFC

__________ __________

Date Date

Are You Ready?

At Lifetime Fitness Center we generally know within a few minutes whether a person will succeed easily or not. If a client accepts our recommendations for changes to their exercise or nutrition program immediately and unconditionally, we know we will achieve success easily. If a client begins to make excuses or give reasons they feel they will not be able to adhere to the program, we can generally expect struggles throughout the process. We supply the following questionnaires to clients to help us determine where they are on the “readiness to change scale”. If you score low, this may not be the best time for you to initiate major changes to your lifestyle. It does not mean, however, that you cannot begin an exercise program. If you score moderately, expect a few struggles on route towards your goals. If you score high, this is the perfect time for you to begin taking actions towards your goals.

Readiness Questionnaire I. Mark the answer that applies to you

  1. Do you feel you are at some sort of health risk because of your current ٱ YES ٱ NO


  1. Do you feel that making lifestyle changes will improve your quality of life and ٱ YES ٱ NO

decrease your risk of health-related disorders?

  1. Do you view your health and fitness program as a lifetime goal rather than a ٱ YES ٱ NO

short-term, temporary goal?

  1. Are you willing to get personally involved in planning a health and fitness ٱ YES ٱ NO


  1. Are you willing to try different approaches? ٱ YES ٱ NO

  2. Do you have the patience to accept success in small increments and deal with ٱ YES ٱ NO

possible setbacks?

  1. Are you willing to set realistic goals? ٱ YES ٱ NO

  2. Are you willing to make lifestyle changes? ٱ YES ٱ NO

If you answered “Yes” to all of these questions, you are ready for action! If you said “No” to one or more of the questions, you might experience resistance as you begin to initiate many of the actions required to achieve your goals. It may be helpful for you to review what is really important to you and learn more about the negative effects of your current behavior and the benefits of change.
Readiness Questionnaire II. Circle the answer that applies to you

Motivation scale (1-5) 1= not at all/ 5= extremely

  1. Compared to previous attempts, how motivated are you 1 2 3 4 5

this time to adhere to your exercise program?

  1. How certain are you that you will stay committed to an exercise 1 2 3 4 5

program for the time it will take to reach your goal

  1. Considering all outside factors in your life (work, stress, family 1 2 3 4 5 obligations, etc.) to what extent can you tolerate the effort required

to stick to a lifetime exercise and nutrition plan?

  1. Think honestly about your goals. How realistic are they? 1 2 3 4 5

  2. How confident are you that you can avoid binging on your 1 2 3 4 5 favorite foods and changing your eating habits?

  3. How motivated are you to work regular exercise in your daily 1 2 3 4 5

schedule, starting tomorrow?

Score: 6-12= Low Motivation 13-25= Moderate Motivation 25+= High Motivation

The database is protected by copyright © 2017
send message

    Main page