RetroFit Roadmap Questionnaire Date: Date Format: MM slash DD slash YYYY Email:* Name First Last Date of Birth: (Ex. January 7, 2019)Address Street Address City State / Province / Region ZIP / Postal Code Cell:*Preferred Form of Contact: (choose one) Cell Email Text Other If OTHER, please describe how best to contact you:Occupation:*Physical Activity Level:*Daily2-3 Time per WeekThis is my first time working outWork Schedule:*I work regular hoursI work irregular hoursI make my own scheduleFitness Goals and AccomplishmentsIf we were meeting 1 year from today, and you were to look back over the last year to today, what has to have happened during that period for you to feel happy about your progress? (please write a book here. The more detailed the better.)If we can figure this out, what value will this bring to your life? What doors will it open? How will your life be better?How will we know we are on track? What can we measure along the way?Fitness Focus PointsOn a scale of 1-10 how important are each of these ideas to you for working out and reaching your fitness goals? How important is building muscle to you?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is gaining strength to you?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is dropping weight/bodyfat?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is improving cardiovascular endurance?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is sweating during a workout?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important to you is improving your overall health?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is working out to feel better?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is working out to look better?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is working out to prevent injury?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is working out to increase energy?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is learning proper exercise form?1 = Not Important2345 = Somewhat Important678910 = Very ImportantHow important is variety?1 = Not Important2345 = Somewhat Important678910 = Very ImportantFitness ExperienceHow do you feel about pushing through pain and/or discomfort? (1-I stop at the first sign of discomfort and 10 is “ no pain, no gain”1 = Stop at the first sign of discomfort2345 = Can handle it at this level678910 = No Pain, No GainAnything you’d like to add to explain the number you chose?Have you ever worked with a trainer or done instructor led fitness training?YesNoIf YES, what have you done? (1 on 1, small group, cross fit, spin, orange theory, yoga,etc)What have you been doing most recently to try and accomplish your health/fitness/performance goals?*Tell us a little about your likes/dislikes and tell us what’s worked for you in the past/maybe what’s not worked in the past?*What have been your biggest struggles when it has comes to accomplishing your health/fitness/performance goals-currently and/or in the past?*Wellness Self EvaluationOn average, how many hours of sleep do you get every night?12345678910Do you sleep through the night?YesNoSometimesDo you wake up feeling rested/energizedYesNoSometimesDo you struggle with energy throughout the day?YesNoSometimesHow do you feel like you’re currently doing with your nutrition?GreatCould be betterTerribleOtherIf "OTHER" please explain:How would you describe your overall stress levels?LowModerateHighHealth and InjuryHave you EVER suffered or been diagnosed with any of the following? Pulmonary Disease Cancer Seizure Allergies Hernia Joint Pain/Injury/Condition High Cholesterol Difficulty Breathing Vascular Disease Recent Illness Diabetes Tremors Lower Back Pain Upper Back / Neck Pain Shoulder Pain Knee Pain Ankle Pain Unusual Fatique Broken Bones Heart Attack / Stroke / Arrhythmia Asthma None of the above Any other injuries/concerns? Please list (nothing is too small)Please list any surgeries (dates/types?)-We don’t need to know about routine procedures like wisdom teeth, tonsils,etc but if you had surgery that was due to a complication, injury or event that impacted your ability to take part in your daily activities of living please list them out.Do you have a history of your father or male first-degree relative suffering from a MI or sudden death before age 55?YesNoDo you smoke?YesNoHas your doctor said you had a heart condition and that you should only do exercise recommended by your doctor?YesNoDo you have pain in your chest when you do physical activity?YesNoIn the past month, did you have pain in your chest when you did physical activity?YesNoDo you lose your balance because of dizziness or do you ever lose consciousness?YesNoDo you have a bone or joint problem that could be made worse by a change in your physical activity?YesNoDo you know any other reason why you should not do physical activity?YesNoAre you taking any medications?YesNoIf yes please list the medications:If my health should change so that I could answer YES to any of the above questions or medications during our time together I understand that I am responsible for informing RetroFIT Training Center, LLCYesNoEmergency Contact:Name First Last Relationship:Phone:Just for fun! How would your best friend describe you?
