Driver Health & Fitness Form

GENERAL INFORMATION

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

HEALTH & FITNESS SECTION

Please select or answer all questions. Try to be as accurate as possible.

Gender

Male
Female

Weight (lbs.)

Height (Example: 6'2")

I would describe my fitness level as:

I regularly do the following exercises:

Walking
Running
Jumping jacks
Push-ups
Sit-ups
Lift weights
Ride bike
Other

(Check all that apply.)

What other form of exercise do you perform?

I can do the following number of push-ups:

I have a health club membership to:

What is the name of the health club you belong to?

I can jog/run without stopping for:

I exercise:

My workouts usually lasts:

I understand the following fitness concepts:

Max heart rate
Target heart rate
Interval training
Multi-muscular exercise
High intensity training
I don't understand any of it

NUTRITION SECTION

Please select the answer that most accurately applies to you.

I would describe my diet as:

I eat breakfast:

I drink the following amount of soda every day:

1 can/bottle (8 ounces)
2-3 cans/bottles (16-24 ounces)
4-5 cans/bottles (32-40 ounces)
6 cans/bottles or more (48+ ounces)

My biggest meal of the day is:

Breakfast
Lunch
Dinner

I know the calories of the foods I eat:

Always
Most of the time
Sometimes
Never

Please select all the snacks that you regularly eat:

I eat fast food (MCD's, Burger King, Wendy's, Taco Bell, Pizza Hut, etc.)

Less than 25% of the time
25-50% of the time
50-75% of the time
More than 75% of the time

After dinner I eat dessert:

Always
Most of the time
Sometimes
Never

I drink the following amounts of coffee on a daily basis:

0 cups
1 cup
2-3 cups
5 cups or more

I drink energy drinks/shots or take energy pills/capsules:

Never
A few times a week
Every day
A few times every day

I drink energy drinks/shots or take energy pills/capsules:

Never
A few times a week
Every day
A few times every day

I regulary take:

Multi vitamins
Dietary supplements
Cleansers

I understand the following concepts:

Metabolism
Nutrient timing
Thermogenic effect of feeding
Resting metabolic rate
I don't understand any of these

What are your fitness and weight loss goals for 2016/2017?

How do you feel about exercise?

What is it that prevents you from exercising regularly?

What do you feel is going to be the biggest challenge to achieving your fitness and weight loss goals for 2016/2017?

Do you have a smartphone? What kind? Do you have web access on your phone? Is it bluetooth compatible?