EveryBody-LOSES Pre-Participation Questionnaire

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Pre-Participation Questionnaire

This questionnaire is another big step towards your commitment. Please tell us a little bit about yourself below so your team trainer can customize this experience whenever he or she deems it appropriate. (We also ask these questions as we are piloting this program and are always looking for ways to evolve and improve all of our programs. We thank you for any feedback you can provide.)

Contact Information

First Name:
Last Name:
Home Phone:
Work Phone:
Mobile Phone:
Can your trainer text message you reminders, tips, etc?	YES NO
What venue will you be registering?	THE HEIGHTS Webster Groves
Can your trainer text message you reminders, tips, etc?	YES NO
Email:
Did someone recommend to you to begin exercising or lose weight?	No, decided on my own Yes, my Doctor Yes, my spouse Yes, a friend Yes, other
How did you hear about the EveryBody-LOSES Competition?	I'm on the emailing list. I train with an EBF Trainer. I saw the poster at The Heights Friend recommended Other

Personal / Lifestyle Information

Age:
Birth Date:	Month: Day: Year:
What was your approximate weight at 18 years of age?
How much has your weight fluctuated in the last 3 years?
Average hours of sleep each night?
Do you smoke?	Yes No
If yes, are you planning to quit in the next 12 weeks?	Yes No
Do you live with a smoker?	Yes No
Do you drink alcohol?	Yes No
How many drinks do you have during the week?
During the weekend?
If you are consuming 5+ drinks per week, have you considered a plan to reducing this?

Exercise History

Are you currently involved in a regular exercise program?	Yes No
How often do you exercise? (Exercise, for now can be defined as any consistent physical activity, i.e. walking, jogging, lifting weights, or rec sports lasting more than 30 minutes continually at a time.)	Never Rarely 1 x/week Several x / week Daily
Where do you typically exercise?	Fitness Center Home Outside Exercise Class
What fitness center or "other" venue do you exercise or take a class?
What form of cardio do you enjoy the most? Please provide any other details here about your exercise (i.e. do you do Pilates, yoga, walk in the park, walk the dog, swim, nothing right now, etc.)
How long does a typical exercise session last for you?
What does a typical exercise session consist of?	Cardio Stretching Upper Body Strength Lower Body Strength Core Strength
Please include any other details below you consider appropriate. (e.g. did you feel better or worse at the end of the workout?

Physical Activity Readiness Questionnaire (PAR-Q)
For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Please read and check the yes or no opposite the question.

Yes No	Has your physician said you have a heart condition or should only do exercises recommended by a physician?
Yes No	When you do physical activity, do you feel pain in your chest?
Yes No	When at rest, or not doing physical activity, have you had chest pain in the past month?
Yes No	Do you ever lose consciousness or do you lose your balance because of dizziness?
Yes No	Are you currently taking prescribed medications for your blood pressure or heart condition?
Yes No	Are you over the age of 65?

*If your health changes and answers above are altered, please notify your personal trainer, and we will discuss seeking guidance from a physician.

Personal Medical History

Have you had any surgeries that effect your physical activity? Yes No
List and briefly describe below:
Surgery, Year, Any post-surgical complications?

Do you have any other aches and pains (i.e. low back) that hinder or may hinder your exercising? Yes No

Please give us any relevant details about your aches and pains.

Have you ever been diagnosed with, or experienced any of the following? (Click all that apply)

Rapid / Irregular Heart Beat
Hypertension
Calf pain with exercise
Varicose veins
Stroke

High blood cholesterol
High blood triglycerides
History of blood clots
Shortness of breath
Glucose Intolerance

Do you take medications for any of the conditions selected here?
For my hypertension, I take . . .

Competition Goals

Please be specific about any long and short term goals, detailing what your goal weight may be, how many pounds or what size belt or dress you'd love to see, along with any habitual goals you are considering (i.e. "I want to eat more fruit each day as one of my goals" below:

In a nutshell, what motivates you? What motivates you to work towards the goals listed above? What has motivated you in the past?

Who do you discuss your health and fitness goals / roadblocks with? Who is your support group? Your spouse? Your co-workers? Or this is one of the reasons you've joined this program?

What has happened, if ever in the past, that may have caused you to lose this motivation, or fall off track?
Did not see any results
Got bored
Not enough direction, not really sure what to do or how to progress with exercise
Personal life experience (Career change, had baby, injury, other)
Too busy with work and/or family, (long hours, lots of travel, family obligations)
It just happened, I don't really have that great of an excuse
Anything else? Please explain:

Commitment
How many days a week can you or are you willing to commit to these goals? (Give or take a day)

How much time do you have per workout session?

Nutrition
How would you rate your nutritional habits as of today?

Do you normally eat breakfast? Yes No

What was your breakfast this morning? Is this typical?

How many meals do you typically eat in a day? (A snack is considered a meal.)

How many times do you eat out a week?

Do you or have you supplemented with any of the following (Check all that apply):

Multi-vitamin
Individual vitamins / minerals
Protein powder
Herbal supplements
"Energy supplements"
Supplements for joint support

Creatine
Amino acids
"Fat Burners"
"Fat Blockers"
Fiber supplement
Other

Can you tell us a little bit about the supplements you take or have tried, i.e., type of protein, what individual vitamins, what brand fat burner?

How would you describe your "nutritional focus"?
I have no nutritional focus
Low Fat
Low Carb
Everything in moderation
Small portion sizes
Grilled chicken & spinach during the week, wings and beer on the weekend
Other (Explain below):

Do you follow, or have you followed a specific diet? If so, check the appropriate one and explain below.
South Beach Atkins Weight Watchers Jenny Craig Zone Diet 40-30-30
Other

Fitness Information
Where do you get most of your health and fitness information? (Click all that apply.)
Fitness Magazines Internet Newspaper Doctor Other Magazines TV
Book(s) Other

Have you ever ordered a fitness product online? (Book, DVD, Exercise Equipment)

Availability for Team Workouts:
In the text box below, plesae tell us your available days and times of day that may be good for scheduling workouts. This is extremely important as we are coinciding these requests with that of the other participants and with the EBF Trainers' schedules. Please tell us the days and time of day you may be able to meet to exercise:

We plan to take a group photo, along with optional, individual "before" pictures, please let us know if you would like to get your picture taken. (Your attire is completely optional, we want to pilot this program to be somewhat like the show, but we won't be asking people to stand up in front of everyone in their sports bras and boxers.) Let us know if you have any other questions or comments.

Thank you so much. Now get ready to make a committment to yourself and those around you. Now, get ready TO LOSE!! Please click the SUBMIT button only once, it may take a minute to process.