RVC Fitness Orientation Questionnaire Welcome to the Club! Please tell us a little about yourself and your fitness preferences. Question Title * 1. Your email address Question Title * 2. Member First Name Question Title * 3. Member Last Name Question Title * 4. Do you prefer a nickname? Question Title * 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? 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. Question Title * 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. 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) Question Title * 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. Question Title * 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. 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) Question Title * 9. Have you worked with a Personal Trainer/ Coach in the past? Yes No Was it a valuable experience for you? (please specify) Question Title * 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? 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) Question Title * 11. What long-term fitness goal(s) do you have for yourself? (specific amount of weight loss/gain, participate in a sporting event, etc.) Question Title * 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.) Question Title * 13. Is there any other information you would like to add that could help us connect you with one of our Personal Trainers/ Instructors? Question Title * 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? Yes No If Yes, please describe briefly. Question Title * 15. Do you feel pain in your chest when you do physical activity or at rest? Yes, occasionally I have chest pains WITH physical activity. 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. Question Title * 16. Do you lose your balance occasionally due to dizziness? or do you ever lose consciousness? Yes No If Yes, please explain briefly. Question Title * 17. Do you have a bone or joint issue that you believe could be made worse by a change in your physical activity? Yes No If Yes, please describe. Question Title * 18. Has your healthcare provider prescribed any medications for a medical condition that you have? If yes, please briefly list those medications. Yes No If Yes, please list medications. Question Title * 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.) Yes No If Yes, please describe. Question Title * 20. Do you have a cardiovascular disease? (heart attack, stroke, arrythmia, palpitations, etc.) Yes No If Yes, please describe. Question Title * 21. Do you have a respiratory disease? (COPD, asthma, etc.) Yes No If Yes, please describe. Question Title * 22. Do you have a metabolic disease? (Diabetes, hyperlipidemia, hypertension, etc.) Yes No If Yes, please describe. Question Title * 23. Have you had any orthopedic/spinal surgery? and/or recent surgery within the last 6 months? Yes No Question Title * 24. If you have had any surgeries, please list all below. Question Title * 25. Do you have high blood pressure? Is it managed with or without medication? Yes, it is managed WITH medication. Yes, but I do not need to take any medication. No Question Title * 26. Do you have low blood pressure? Yes, it is managed WITH medication. Yes, but I do not need to take medication. No Question Title * 27. Do you have high cholesterol? Yes, it is managed WITH medication. Yes, but I do not need to take medication. No Question Title * 28. Have you ever had a concussion? Yes No If Yes, please list number of events & briefly describe. Question Title * 29. Have you had any other type of traumatic brain injury (TBI)? Yes No If Yes, please briefly describe. Question Title * 30. Do you suffer from unexplained shortness of breath? Yes No If Yes, does your healthcare provider know? Question Title * 31. Do you suffer from unexplained fatigue? Yes No If Yes, does your healthcare provider know? Question Title * 32. Do you suffer from shoulder pain/injury? Yes No Question Title * 33. Do you suffer from elbow pain/injury? Yes No Question Title * 34. Do you suffer from hand/wrist pain/injury? Yes No Question Title * 35. Do you suffer from spine pain/injury/disorder? Yes No Question Title * 36. Do you suffer from hip pain/injury? Yes No Question Title * 37. Do you suffer from knee pain/injury? Yes No Question Title * 38. Do you suffer from ankle pain/injury? Yes No Question Title * 39. Do you suffer from any other injury or pain disorder(s)? Yes No If Yes, please briefly describe. Question Title * 40. Are you interested in more information about any of the following specialties we offer here at the River Valley Club? 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? Done