Marjie Gilliam - Custom Fitness Personal Training Services Fitness Plan Questionnaire Page

Weight Training, Cardio, & Nutrition Questionnaire

The following questionnaire may be submitted electronically, or printed and mailed in care of Marjie Gilliam to the address below:

Custom Fitness Personal Training Services
PO Box 1586
Fairborn, Ohio 45324
(937) 878-9018

Instances where submitting the questionnaire is most useful:

- You have contacted CFPTS for a Personal Consultation. Consultations are provided via internet, locally by phone, or face to face meeting in a health club environment.

Consultation Fee $75.00 per hour. On-line payments are not accepted. Please send a certified check or money order payable to Marjie Gilliam at the address listed above.

Your questionnaire is processed and you will be contacted, when payment is received. Note that although most questionnaires are generally processed immediately following payment, allow one to two weeks for contact as processing time is dependent upon the complexity of information received.

Depending on individual goals and objectives and/or program desired, consultation times vary in length, but typically require no longer than 1 hour to complete. Topics discussed may vary, and typically include health history, current and part exercise experience, nutritional habits and goals.

Once the consultation is complete, you will be provided with a weight training chart suited to your goals, listing names and proper order of each exercise, and number of reps and sets and days per week that your exercise program is to be performed. Your chart will be mailed to you unless you are requesting a face to face consultation, in which case it is delivered at this time.

-- Please complete the following contact information:
(The information entered will remain in strict confidence and WILL NOT be given out for any reason!)

First Name:

Last Name:

e-mail address:

   (must be included)

Address 1:

Address 2:

City:

State:

Zip Code:

Home Phone:

   (include area code)

Bus. Phone:

   (include area code)

-- Please complete the following general information:

Occupation:

Height:

Male:

Female:

Date of Birth:

Current Weight:

Desired Weight:

Bone Structure:

Small

Medium

Large

Activity Level:

Very Low

Low

Medium

High

Very High

Do you smoke?

No:

Yes:

If Yes, Packs/Day:

Do you drink alcohol?

No:

Yes:

If Yes,
What is your consumption?

Beer: oz/week

Wine: oz/week

Liquor: oz/week

Please indicate your fitness goals:

Increase Muscle

Reduce Fat level

Tone Up

Increase Energy

Other (Please provide as much detail as possible)

In order for me to design a personalized program for you, please answer the following questions to the best of your ability.

Please indicate the type of program you desire (for complete descriptions, refer to the SERVICES Page):
Beginner - Phase I
Beginner/Intermediate - Phase IIA
Intermediate - Phase IIB
Advanced - Phase III

1.    Do you participate in sports?

No

Yes

If Yes,
please indicate type of sports:

(Please provide as much detail as possible)

2.    Have you ever performed weight training exercise?

No

Yes

If Yes,
please indicate your training experience:

Beginner

Intermediate

Advanced

3.    Do you have any past or current medical problems that include, but are not limited to: diabetes, asthma, epilepsy, heart disease, high blood pressure, etc.)?

No

Yes

If Yes,
please explain:

(Please provide as much detail as possible)

Enter date of last physical:

4.    Do you have any joint problems (double jointed, lack of range of motion, "trick knee", etc.)?

No

Yes

If Yes,
please explain:

(Please provide as much detail as possible)

5.    Have you had any operations in the last two years?

No

Yes

If Yes,
please explain:

(Please provide as much detail as possible)

6.    Are you currently taking any medications?

No

Yes

If Yes,
please explain:

(Please provide as much detail as possible)

-- The following questions pertain to your current weight training activities.

7.    Where do you plan to weight train?

Gym

Home

Other:

8.    Do you have a training partner?

No

Yes

9.    What kind of equipment do you prefer?

Free Weights

Machines

10.    Which days of the week would you like to weight train?

Monday
Tuesday
Wednesday
Thursday

Friday
Saturday
Sunday

11.    How much time can you devote to each weight training session?

30 min.

45 min.

60 min.

Other:

12.    Please indicate the names and types of weight training equipment available to you:

(Please provide as much detail as possible)

13.    Please provide your current weight training log information (including weights, sets, reps, days per week, name of exercise and on which days):

(Please provide as much detail as possible)

-- The following questions pertain to your current level of aerobic/cardiovascular fitness.

14.    Which days of the week would you like to do cardiovascular training?

Monday
Tuesday
Wednesday
Thursday

Friday
Saturday
Sunday

15.    How much time can you devote to each cardiovascular training session?

30 min.

45 min.

60 min.

Other:

16.    What type of cardiovascular exercise do you prefer?

Cycling

Stepper

Treadmill

Running

Other:

17.    Please indicate the names and types of cardiovascular training equipment available to you:

(Please provide as much detail as possible)

18.    Please provide your current cardiovascular training log information (including days per week and on which days):

(Please provide as much detail as possible)

-- The following questions pertain to your current dietary habits.

19.    Have you tried "dieting" before?

No

Yes

If Yes,
What have you tried?

(Please provide as much detail as possible)

20.    Are you allergic to any foods?

No

Yes

If Yes,
What are your food allergies?

21.    Do you have a lactose intolerance?

No

Yes

22.    Are there any foods you refuse to (or do not) eat?

No

Yes

If Yes,
please describe:

23.    Which of the following meals do you currently eat, and at what time do you eat them?

Breakfast
Time

Morning Snack
Time

Lunch
Time

Afternoon Snack
Time

Dinner
Time

Evening Snack
Time

24.    Prefer protein (meat, fish, poultry, etc.)?

No

Yes

25.    Prefer carbohydrates (pasta, rice, potatoes, fruits, sweets, breads, etc.)?

No

Yes

26.    Prefer fats? (sauces, butter, fried foods, bacon, sausage, etc.)?

No

Yes

27.    Please indicate any regular eating habits you have (i. e. dining out on weekends, late night eating, cravings, etc.):

28.    Please list ALL the foods you have eaten in the last forty-eight hours:

29.    How many 8 oz. glasses of water (excludes soda, coffee, tea, etc.) do you drink each day?

Enter Average per Day:

30.    How many meals per day do you eat?

4

5

6

7

-- How did you hear about Custom Fitness Personal Training Services:

-- Do you have any comments, questions, or concerns regarding the programs?

Disclaimer: Custom Fitness Personal Training Services is not responsible for any injury or harm incurred by following an unsupervised program. Please consult a physician before beginning any strenuous exercise program.

Copyright (c) 2008 Marjie Gilliam. All the content comprising this web site, including all the graphs, graphics, photographs, texts, sounds, data, audio and video clips available on this web site, is the property of Marjie Gilliam, and is protected by U.S. and international copyright laws. The compilation, collection, selection, arrangement, assembly, and coordination of all content available on this web site is the exclusive property of Marjie Gilliam and is protected by U.S. and international copyright laws. Information received through this web site may be printed for your personal, non-commercial use only. You agree not to reproduce, retransmit, distribute, disseminate, sell, publish, broadcast or circulate the information received through this web site to anyone. Any copy made of information obtained through this web site must include the copyright notice.

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