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RVC Fitness Orientation Questionnaire
Welcome to the Club! Please tell us a little about yourself and your fitness preferences.
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1.
Your email address
(Required.)
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2.
Member First Name
(Required.)
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3.
Member Last Name
(Required.)
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4.
Do you prefer a nickname?
(Required.)
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5.
Your RVC membership includes a Fitness Assessment and a Fitness Orientation with one of our specialized personal trainers. What specialty would you prefer your Fitness Orientation with?
(Required.)
Fitness Floor (weight training, circuit training, conditioning, general fitness)
CrossFit (CrossFit, Olympic lifting, power lifting)
Pilates/ Reformer Studio (Pilates and Reformer)
Yoga Studio (Private Yoga)
Lap Pool (swimming)Temporarily closed for Renovations.
Recreation Pool (aquatic exercise) Temporarily closed for Renovations.
Would like a recommendation after my Fitness Assessment.
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6.
Would you like your trainer/instructor to have any specific training/ certification/experience? (i.e. weight loss, sport-specific, injury prevention) Select all that may apply.
(Required.)
Sports Specific (marathon, running, team sports, etc.)
Weight Loss & Conditioning
Muscle Gain & Toning
Nutrition Education
Recovery from Injury/Surgery or Transitioning from Physical Therapy
Joint Pain, Increase Flexibility, Injury Prevention
No preferences
Other (please specify)
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7.
RVC offers Nutrition Education packages with a Certified Personal Trainer, would you like specific details about this option? If yes, please add your comment.
(Required.)
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8.
What are the best days and times to meet for your Fitness Assessment and/or with a Personal Trainer/Instructor? Please select all that could apply.
(Required.)
Monday-Friday
Saturday & Sunday
Any day of the week
Only certain days, enter them below.
Day options vary, will communicate details at Assessment.
Early mornings: 5am, 6am or 7am
Mornings: 8am, 9am
Late mornings: 10am, 11am
Early afternoons: 12pm, 1pm,2pm, 3pm
Mid-afternoons: 4pm, 5pm
Evenings: 6pm, 7pm
Other (please specify)
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9.
Have you worked with a Personal Trainer/ Coach in the past?
(Required.)
Yes
No
Was it a valuable experience for you? (please specify)
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10.
Are you specifically interested in starting Personal Training at RVC or would only like to experience the Free Orientation at this time? or are you unsure?
(Required.)
Yes, I know I want to start Personal Training at RVC.
I am not sure at this time whether I would be interested in Personal Training.
No, at this time I would only like to experience an Orientation.
Other (please specify)
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11.
What long-term fitness goal(s) do you have for yourself? (specific amount of weight loss/gain, participate in a sporting event, etc.)
(Required.)
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12.
What short-term fitness goal(s) do you have? (get to the club 3x/week, do a pull-up, change an unhealthy behavior, etc.)
(Required.)
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13.
Is there any other information you would like to add that could help us connect you with one of our Personal Trainers/ Instructors?
(Required.)
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14.
Has your healthcare provider ever said that you have a heart condition and/or that you should be limited to only 'physical activity' recommended by a healthcare provider?
(Required.)
Yes
No
If Yes, please describe briefly.
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15.
Do you feel pain in your chest when you do physical activity or at rest?
(Required.)
Yes,
occasionally I have chest pains WITH physical activity
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No, I have no chest pain during physical activity.
Yes,
occasionally I have chest pains when I am NOT
doing physical activity.
No, I do not experience chest pains.
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16.
Do you lose your balance occasionally due to dizziness? or do you ever lose consciousness?
(Required.)
Yes
No
If Yes, please explain briefly.
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17.
Do you have a bone or joint issue that you believe could be made worse by a change in your physical activity?
(Required.)
Yes
No
If Yes, please describe.
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18.
Has your healthcare provider prescribed any medications for a medical condition that you have? If yes, please briefly list those medications.
(Required.)
Yes
No
If Yes, please list medications.
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19.
Do you have any 'limitations' that either you or a healthcare provider has suggested you follow related to physical activities? (i.e. no impact, no bending, etc.)
(Required.)
Yes
No
If Yes, please describe.
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20.
Do you have a cardiovascular disease? (heart attack, stroke, arrythmia, palpitations, etc.)
(Required.)
Yes
No
If Yes, please describe.
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21.
Do you have a respiratory disease? (COPD, asthma, etc.)
(Required.)
Yes
No
If Yes, please describe.
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22.
Do you have a metabolic disease? (Diabetes, hyperlipidemia, hypertension, etc.)
(Required.)
Yes
No
If Yes, please describe.
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23.
Have you had any orthopedic/spinal surgery? and/or recent surgery within the last 6 months?
(Required.)
Yes
No
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24.
If you have had any surgeries, please list all below.
(Required.)
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25.
Do you have high blood pressure? Is it managed with or without medication?
(Required.)
Yes, it is managed WITH medication.
Yes, but I do not need to take any medication.
No
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26.
Do you have low blood pressure?
(Required.)
Yes, it is managed WITH medication.
Yes, but I do not need to take medication.
No
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27.
Do you have high cholesterol?
(Required.)
Yes, it is managed WITH medication.
Yes, but I do not need to take medication.
No
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28.
Have you ever had a concussion?
(Required.)
Yes
No
If Yes, please list number of events & briefly describe.
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29.
Have you had any other type of traumatic brain injury (TBI)?
(Required.)
Yes
No
If Yes, please briefly describe.
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30.
Do you suffer from unexplained shortness of breath?
(Required.)
Yes
No
If Yes, does your healthcare provider know?
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31.
Do you suffer from unexplained fatigue?
(Required.)
Yes
No
If Yes, does your healthcare provider know?
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32.
Do you suffer from shoulder pain/injury?
(Required.)
Yes
No
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33.
Do you suffer from elbow pain/injury?
(Required.)
Yes
No
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34.
Do you suffer from hand/wrist pain/injury?
(Required.)
Yes
No
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35.
Do you suffer from spine pain/injury/disorder?
(Required.)
Yes
No
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36.
Do you suffer from hip pain/injury?
(Required.)
Yes
No
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37.
Do you suffer from knee pain/injury?
(Required.)
Yes
No
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38.
Do you suffer from ankle pain/injury?
(Required.)
Yes
No
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39.
Do you suffer from any other injury or pain disorder(s)?
(Required.)
Yes
No
If Yes, please briefly describe.
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40.
Are you interested in more information about any of the following specialties we offer here at the River Valley Club?
(Required.)
Tennis and/or Pickleball membership or classes?
Nutrition Education packages?
Reformer/Pilates membership or classes?
CrossFit membership or classes?
Applied Functional Neurology w/Personal Training?
Introduction to the equipment on the Fitness Floor?
