REGISTRATION FORM

Date

Your name

Date of Birth

Your email

Address

Daily Routine

WORK INFORMATION

Nature of work - sedentary YESNO

If outside = requires rigorous physical activity

Vehicle used during job 2 wheeler4 wheeler

Outstation traveling YESNO

PHYSICAL FITNESS ACTIVITIES

Height (in foot and inches)

Weight (in Kg)

Body structure EctomorphMesomorphEndomorph

Walking or Running YESNO

Swimming YESNO

Weight Training YESNO

Yoga YESNO

Aerobics YESNO

Zumba YESNO

Any other – please mention

Will you be on a nutritional diet with you fitness training? YESNO

Purpose of exercise
Need for constant fitnessGrowing oldRequirement of the professionI am into sportsI am fat/obeseI am too thinMy partner wants me to exerciseI am pregnantJust came out of the pregnancy

Which of the following types of fitness training are you interested in?
Resistance trainingInterval trainingContinuous trainingAll of the aboveNone of the above ( please specify)

Which of the following conditioning areas will you focus on?
PowerStrengthAgilityBalanceCardiovascular enduranceFlexibilityLow muscle enduranceCo-ordinationStrength endurance

Which of the following conditioning areas will you focus on?
PowerMuscular StrengthCardiovascular enduranceFlexibilityLow muscle enduranceStrength enduranceSkill related fitnessAgilityBalanceCo-ordinationSpeedPowerReaction time

Time spend for physical activity Less than hourMore than hour

Frequency of exercise 3 days a week4 days a week5 days a weekDaily

If irregular – specific reasons

Sleep Less than 8 hoursMore than 8 hours

Breathing – abdominal YESNO

Daily water consumption Less than 8 litreMore than 8 litre

Daily food intakeBreakfastLunchMid snacksDinner

Have you been critically ill in the past? YESNO

Any specific health issuesHeartChest PainBPCholesterolDiabetes

Any hereditary health issues?

Are you now, on medication for any minor or major health issues?

Do you feel pain in your joints or bones while doing any physical activity?

MENTAL AND EMOTIONAL

Challenges to start physical fitness exercise
Low self imageBoredomCravingsWrong goalsLack of knowledgeHectic livesEating on the runSedentary lifestyleNo time for exerciseLack of will powerLack of motivationSlow resultsImpatient about resultsNo results

Emotional pattern of eating SocialEmotionalAddictiveBig eating

Any serious shock , grief , disappointments, fright , mental upset , depression or nervous break down