Doerz Motivation Fitness Assessment

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You may be asking yourself, with so many services available, where do I begin? Doerz
Fitness Assessment appointment is a great start. Your Doerz Trainer is dedicated
to providing appropriate recommendations by reviewing your health and fitness
questionnaire and performing various assessments and measurements.

The recommendations will be based on your individual needs to help you successfully
reach your short and long-term fitness goals.

Your post-assessment consultation with a Doerz Trainer can be delivered by phone or video conference and may consist of the following:

Review of Physical Activity Readiness Questionnaire (PAR-Q)

Review of Health and Lifestyle Questionnaire

Physical assessment and results review

Review of personal fitness goals

Evaluation of aerobic fitness level

Recommendations and program planning

Some members prefer to have a
coach/personal trainer help them achieve success; some prefer our group fitness or
sports programs, while others prefer to try it on their own.

Your Doerz Trainer will make sure you get started in the right direction!
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How did you hear about us?
Facebook
Instagram
Referral
Google
Website
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Have you ever worked out with a Personal Trainer? * This field is required.
YESNO
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Your Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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Email* This field is required.
example@example.com
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Gender
Male
Female
Decline to Answer
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Age Range* This field is required.
Under 18
18-24
25-39
40-55
Over 55
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Date of Birth * This field is required.
Date
Month
Day
Year
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Height* This field is required.
Feet & Inhes
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Weight* This field is required.Approximate if exact weight is unknown
Lbs
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Do you currently have an injury, a movement limitation, or pain that limits your ability to exercise? (Knees, Back etc)
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Did your physician recommend that you lose weight and/or start an exercise program?
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If you have any diagnosed health problems list the condition (high blood pressure etc)
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Are you taking any medications or drugs? If yes, please list medication, dose, and reason.
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Do you now, or have you had in the past (treatment, diagnosis):
None
Arthritis, Rheumatoid Arthritis, Psoriatic Arthritis, osteoporosis, etc.
Blood pressure (hypertension) or low blood pressure
Heart problems, stroke, or other cardiac conditions
Cancer, MS, Epilepsy or any chronic illness or condition
Difficulty with physical exercise
Advice from a physician not to exercise
Recent surgery (in past 24 months)
Pregnancy (now or within last 12 months)
History of breathing/lung programs (asthma, COPD, emphysema)
Muscle, ligament, tendon, joint (shoulder, knee, hip, ankle, wrist) neck, or back disorder/injury or any previous injury still affecting you
Diabetes (type I or II), thyroid condition or hypo/hyperglycemia
Cigarette smoking habit
Obesity (more than 20 percent over ideal weight)
Hernia or any condition that may be aggravated by lifting weights
Frequent headaches (migraine, cluster, stress/tension)
Frequent colds, flu, upper respiratory infection, strep throat
Depression, Anxiety, Bipolar, SAD, or another mental health condition
Circulatory problems/conditions
Stomach, intestinal, digestive problems/conditions
Chronic sleep problems
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Does your occupation require much activity (i.e. walking, getting up and down, carrying things)?
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Can you exercise during your workday (before, during, or after)?
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How many times a week can you commit to working out?* This field is required.Type a number
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How would you rate your level of stress on a daily basis? * This field is required.
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What areas of your life seem to cause you the most stress?
Health
Finances
Relationships
School/Education
Social
Work
Other
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Does your significant other or a close friend/family member support your efforts in achieving your personal fitness goals? Skip if this does not apply
YESNO
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How many hours of sleep do you get each night? * This field is required.
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Why haven’t you achieved your goals already? What’s blocking you?
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What awesome things might happen to you if you did make progress?
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Give us 2-3 body parts you specifically want to focus on?
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On a scale of 1 to 10 (10 being the most serious) HOW SERIOUS ARE YOU ABOUT ACCOMPLISHING YOUR FITNESS GOALS?
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How long have you been thinking about accomplishing your fitness goals?
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What has stopped you in the past?
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How often are you willing to train per week to reach your goal?
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What are the things that we can help you out with in order to make sure that you are successful?
Variety
Nutrition accountability
Structure
Challenge
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At what times during the day would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
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How many meals are you eating daily?
1
2
3
4
5
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What is your biggest nutritional challenge?
Cravings
Don’t know what I should eat
Eating out frequently
Emotional/stress eating
Time to prep meals
Wine/alcohol
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How many times per day are you currently eating out?
1
2
3
4
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Do you eat breakfast regularly?* This field is required.
YESNO
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Are you now or have you been on any kind of weight loss program (diet) or nutritional program in the past?
YESNO
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What are your primary fitness goals?* This field is required.
Reduce body-fat & weight loss
Improve cardiovascular fitness
Reshape or tone body
Strengthen body
Build muscle
Improve sport specific performance
Increase energy level
Improve flexibility and mobility
Improve self-confidence
Feel better, positive attitude
Maintain my workout consistency
Exercise safely and with proper form
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What do you think your biggest challenge will be in meeting your fitness goal? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
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What is the number one thing you are hoping to achieve from your Personal Training? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
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