Lifestyle Questionnaire

This form is for personal training, we can write you a months schedule if you follow the instructions below:

Important: Use this form or a photocopy only. Spend time to answer the questions fully, the more information the more accurate the schedule.

NAME…………………………. AGE………. SEX M/F...…..

ADDRESS

………………………………………………..

………………………………………………..

………………………………………………..

……………………..Post Code……………..

TEL: …………Mobile………… Fax……………. e-mail………………

HEIGHT………..WEIGHT ………

PAST PHYSICAL TRAINING

…………………………………………………………………………………

…………………………………………………………………………………

SWIM

BIKE

RUN

WEIGHTS

OTHER

APLICABLE P.B’S…1/………...2/………....3/…………4/………..

CURRENT TRAINING – give brief details of what you currently do, make a note of sessions that you do not wish to change.

AM PM .

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

FAVOURITE TYPES OF EXERCISE IN ORDER OF PREFERENCE

1.

2.

3.

4.

5.

6.

FAVOURATE SESSION FOR YOUR CHOSEN SPORT

Goals:

Write out your goals in order of short, medium or long term. They must be realistic and achievable. They can be varied such as weight loss, cardiovascular improvement, more energy, reducing stress, diet change etc. Give yourself plenty of time to think about what you really want and what you think is possible.

An example of these could be:-

Short: = lose 4lbs fat (this probably is achievable)

Medium: = Improve 10K time from 42 minutes to 37 minutes in 4 months. (this may be too long term and I would recommend sub 40 as a medium goal and 37 as a long term goal)

Long: = Run your first marathon in 10 months. This would be a good long term goal.

Remember your goals change all the time!

YOUR GOALS:

SHORT :

MEDIUM:

LONG :

GOAL DIARY: (give an approximate time plan to your goals, I.E. when you think you should reach them or your races when are they? And also a scale of importance - for instance (1 = training 5 = National championships)

TIME AVAILABLE TO TRAIN

Take into account your current training and mention any set sessions that you do not want to stop, such as the Sunday club Bike Ride., or Tuesday night club swim, or Wednesday run with your friends. Also tell me what these sessions normally involve.

If you do no current training then that is OK, just indicate how much time you have available plus how much training you think you can do and when.

AM - mins / hours LUNCH TIME - mins / hours PM - mins / hours

MONDAY

TUESDAY

WEDNESDAY

THUSRDAY

FRIDAY

SATURDAY

SUNDAY

GOOD & BAD POINTS

Please make a comprehensive list of your good and bad points.

For example BAD points could be:- Overweight, inconsistent, family stress, illness, lack of knowledge, poor diet, slow swimmer, hate salads and fruit, etc.

GOOD points could be:- Enjoy running, like to train hard, motivated, plenty of time to train, family backing, training partners, etc.

(be honest and take your time to list everything you think may be valid. This will help me to create the best personalized schedule I can.)

GOOD BAD

HEALTH SECTION

‘CONFIDENTIALITY’

This schedule questionnaire is strictly confidential. Please state if there is anything you can think of that may limit of affect your training in any way:

When was the last time you were ill?…………………..

What was it?……………..

Are you recovering from a major illness?……………..

Are you on any medication and what is it for?………………………………………………………….

What is it:

1……………………………2……………………………3………………………………..

Have your race times been getting worse lately?………….

Have you been exercising without any real problems and only had one or two colds a year?…………

Have you been exercising for more than two years without problems and doing well in racing and training without injury?……………..

I last had a cold……………………..

I last had flu…………………………

How many hours sleep do you get per night on average?………….

My resting pulse is………………….

(take first thing in the morning, a minute or so after you wake. Take it for five days then divide the total by five to give me your average resting heart rate.)

My maximum heart rate is………….

(Don’t Use 220 minus age formula, it is innacurate)

or

Maximum heart rate test I know I don’t know

If you don’t know, this will be discussed before the tests are set.

Do you own a heart rate monitor?…….y/n

I am a Cyclist……… I am a runner….. I am a Studio Cyclist…….. I am a Triathlete….

I am a …..?

I want to be a ………………………………………….

My sizes are S……M…….L……. Waist ………Chest………

Current ‘2002’ Costs (these prices are subject to change without prior notice)

First discussion / consultation + analysis of questionnaire – free

Initial Assessment Day - £175 + extra travel expenses + VAT

(approx. 8 hours inc. work after day) Includes full fitness assessment, swim, bike, run analysis (if applicable) and session, other relevant training options to be used within any monthly schedule, full post report.

One to one training sessions - £35 per hour (unless otherwise agreed)

Monthly Schedule - £80 incl. + VAT per month (weekly or key session schedules available if necessary – cost TBA)

Includes: all types of training: progressive training phases, training zones, contact hotline, logged training analysis, 4 weekly phases, seasonal periodization, goal implementation.

Disclaimer

I know of no reason why I should not follow a physical training schedule or diet program written for me by Rick Kiddle or anyone else associated with his fitness consultants work, NSCR, Heart Zones UK Limited or Internet-spinoffs. I will in no way hold the writers or coaches responsible for any loss, theft, damage, accident, illness or injury to me.

Full Name………………………..

Signed……………………………..Date………