Welcome to Original Workout
About OW
Fènix Jiu-Jitsu
Trainers
Rob Goodwin (Founder)
Ryan Gant
Daniel Fredell
Reon Mcilwain
Zach Fesperman
Jason Bebber
Keto-Lifestyle
FREE Session
Contact
Client's Area
Wanted: Trainer
Welcome to Original Workout
About OW
Fènix Jiu-Jitsu
Trainers
Rob Goodwin (Founder)
Ryan Gant
Daniel Fredell
Reon Mcilwain
Zach Fesperman
Jason Bebber
Keto-Lifestyle
FREE Session
Contact
Client's Area
Wanted: Trainer
Search by typing & pressing enter
YOUR CART
Client Profile Questionnaire
* All information on this questionnaire is private and confidential. No one will read it or have access to it but your trainer. We strongly believe in client / trainer confidentiality.
Basic Information
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Indicates required field
Name
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First
Last
Age
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Gender
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Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
How did you hear about us?
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Do you take any medications, either prescription or non-prescription, on a regular basis? Yes/No What is the medication for?
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Please list any surgeries or serious illness in the past 12 months
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Main fitness goal
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Lose Weight (Fat)
Get fit
Build Muscle
Sport specific
Injury rehab
Physique competition
Nutrition Education
Design a more advanced program
Any additional goals?
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If weight loss is your goal, how many pounds do you feel you need to lose?
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Last time you worked out? (Month & Year)
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Have you ever worked with a Personal Trainer?
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If exercising currently, please give an explaination of a typical workout week
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List any chronic injuries
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Have you ever been advised by a physician to avoid any type of exercise?
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Have you ever had any injuries resulting from training?
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Please pick your perceived level of current fitness
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Poor
Average
Above average
Fit
Very Fit
Advanced
How many hours do you sleep each night?
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Do you sleep well?
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Do you smoke?
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Anything else you feel is important for me to know?
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Life & family
Do have children? Yes or No
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If yes, how many? Ages:
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Living situation : (Family, husband, roommate, parents, siblings, boyfriend, girlfriend?) etc. Please list :
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Is there someone within the home that is very unsuppotive in your pursuit of a complete lifestyle and dietary change?
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What are some obstacles (behaviors, stress, activities, etc) that you foresee impeding your success?
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What are your favorite non-fitness related hobbies?
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Work
Where do you work?
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What is your typical work schedule during week or weekend?
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Do you feel it's hard to keep healthy eating habits where you work or in your home?
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What does a typical day of eating look like during work week?
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Simply list a simple example of a typical day's menu
eating out & foods
How often do you eat out weekly?
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Do you like to cook?
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How often do you cook dinner at home? Please list your typical dinner you would prepare:
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List your favorite cheat foods
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Would you say you have a food addiction?
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My biggest downfall is:
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Carbs
Sugar
Soda / Sweet tea
Alcohol
Fast food
Salty processed snacks
Chocolate
My favorite healthy foods are:
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Have you tried any "diets" in the past year? (Paleo, Ketogenic, Low fat, low carb, etc)
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Do you drink coffee?
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Do you make protein shakes / smoothies?
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Are you a Vegan or Vegetarian?
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Choose Any that you WILL NOT eat:
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Eggs
Red meat
Fish
Poultry
Protein Powder
Green vegetables
How many days per week do you consume alcohol?
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I regularly consume
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Wine
Beer
Mixed drinks / Cocktails
Straight liquor
exercise
Will you be working out at home or a local gym?
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If a local gym, please list name and location
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Do you take any workout classes currently? If yes, please list:
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If working out at home, please list any equipment you have:
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Aside from a gym or group classes, what other physical sports or activities to you participate in ? (Ex: hiking, running, bike riding, etc.)
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Is there a specific event in your life in the near future you're attempting to be ready for? List type of event and / or date:
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*If applicable, when training in the gym do you prefer more traditional strength training / weight lifting or do you prefer faster paced circuit style workouts?
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Traditional strength training / weight lifting
Faster paced circuit training
I like to mix it up
I'm too new at this to have an opinion
Your Body
Current weight
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Height
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Current Dress Size (Women)
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Current Pant Size
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On a scale 1-10, How determined are you?
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1 = Not very, 10 = Most determined I've ever been!! I will not fail!!
Please upload your current "before" photo(s). We recommend a current photo taken in shorts / spandex shorts and a sports bra
*Absolutely no one will see this photo but your trainer. Regular photos are critical for the online training experience to work. Your trainer must visually see you to gauge progress and to determine any changes in program to ensure success.
Upload File (Front Pic)
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Max file size: 20MB
Upload File (Back Pic)
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Max file size: 20MB
Upload File (additional)
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Max file size: 20MB
INFORMED CONSENT FOR FITNESS TESTING/PERSONAL TRAINING AND WAIVER OF LIABILITY
I, the undersigned, do hereby certify that to the best of my knowledge, I am physically able to begin a program of moderate or strenuous exercise and conditioning. I do not have any medical problems or ailments that would put me at risk if I were to become involved in an exercise program. If I am over the age of 42 and unaccustomed to vigorous exercise, I understand that a medical exam, including an EKG test is advised prior to beginning my exercise program. I acknowledge that I have either had a physical examination and consultation with a physician or have been given permission to participate in such activity without the approval of my physician and do hereby assume all responsibility for my participation. I will not hold Original Workout, Rob Goodwin, Nancy Goodwin, any partnership, corporation or DBA thereof, or any employees or individuals contracted by, Original Workout, liable for any injury or injuries. I am entering an exercise program at my own risk with a complete understanding that the strength training, flexibility development, and aerobic/cardiovascular exercise I am about to become involved in is potentially dangerous. I hereby agree to expressly assume and accept any and all risks including -but not limited to -heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries, and any other illness, soreness, injury, or death, however caused occurring during or after my participation in the exercise program. I, the undersigned, also understand that any nutrition and nutritional supplementation advice is for information purposes only and is not intended for my individual prescription. And, if I decide to follow any such information I do so at my own risk.
By initialing and entering your name in the electronic signature box below, you agree to the above waiver of liability and hereby agree that your electronic signature is legally binding.
Initials
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Electronic Signature
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Submit
