Interest Packet Material

Requester Name

Requester Email

Eagle ID

Gender
MaleFemale

Date of Birth

Age

Daytime Phone

Evening Phone

Address

City

State

Campus Affiliation
FacultyStaffStudent

Expected Graduation Date (students only)

Name of preferred Personal Trainer (if applicable)

Preferred trainer gender
No preferenceMaleFemale

How do you like to be motivated?

Preferred Training Specialty (check all that apply)
Partner TrainingGeneral Health & FitnessWeight LossMuscle BuildingYoga/PilatesCardio/EnduranceFlexibilitySpeed & AgilityPower/Strength TrainingOlder AdultsAquatics TrainingObesity

If you checked partner training, with who?

Please state the time ranges you are available to train; specify AM or PM, or if not available.

Overall Fitness Goal

Six Months Fitness Goal

One Month Fitness Goal

What type of activities/exercises would you like to learn/perform during your training sessions?

How much time are you willing to devote outside of your scheduled training sessions to reach your goals?

1. In the past six months, how often have you been engaged in physical activity? Regularly (3 to 4 times/week)Semi-regular (1 to 2 times/week)Sporadic (1 to 2 times/month)None

2. Do you have any negative feelings toward, or have you had any bad experiences with, physical activity programs including specific experiences at the RAC?

3. Check the number that corresponds to the response which best describes you for each of the following statements.
(1= low ability/interest, 5 = high ability/interest)

Importance of completion during exercise.

12345

How hard do you like to be pushed or motivated during exercise?

12345

Present cardiorespiratory (aerobic) fitness.

12345

Present muscular fitness.

12345

Present flexibility.

12345

4. Do you start exercise programs but then find yourself unable to stick with them?

5. Are you currently involved in regular cardiorespiratory (aerobic) exercise?

6. Are you currently involved in a regular weight training program?

7. Rate your perception of the exertion of your exercise program LightFairly lightSomewhat hardHard

8. What other exercise, sport or recreational activities have you participated in the last six months?

9. What types of physical activity do you consider “fun”?

10. Have you ever experienced soreness after a workout? YesNo

11. Do you experience any chronic pain?YesNo

12. On average, how many hours of sleep do you get in a 24-hour period?9-10876 or less

13. Are you a cigarette smoker?YesNo

14. Did you previously smoke cigarettes?YesNo

15. Do you drink alcoholic beverages?YesNo

16. Please list any other considerations or information your trainer should be aware of before getting started? (ex. medications, supplements, injuries, exercise or activities you can't/won't perform, effective motivation techniques for you, etc.)

1. Are you currently on a special diet? (i.e., vegetarian, low-carb, high protein, etc)YesNo

2. Are you currently taking any vitamin or nutritional supplements?YesNo

3. How many pieces of fresh or frozen fruit do you eat each day? (a portion based on ½ cup)More than 31-31 or less

4. How many portions of fresh or frozen vegetables do you eat each day? (a portion based on ½ cup)More than 74-72-41 or less

5. Do you drink caffeine?YesNo

6. Where do you eat most often?HomeFast Food (Wendy’s, McDonald’s, Taco Bell, etc.)Sit-down restaurants (Olive Garden, Ruby Tuesdays, Millhouse, etc.)WorkOther

7. What are your favorite types of food?

8. What do you find yourself craving?

9. How many glasses of water do you drink per day?0-23-56-89-12

10. How many soft drinks do you drink per day?0-23-56-89-12

11. How many meals and/or snacks do you have per day?

12. Do you feel you eat healthy most of the time?YesNo