Online Fitness Training Application Form INSTRUCTIONS This is our Online Fitness Training Application Form, where we ask you to provide relevant personal information. All information provided will be kept completely confidential and used to help design an optimized individual fitness program and nutritional guidelines for you. Please answer all questions as accurately and thoroughly as possible.

You can either type your responses into the document or print and write by hand (then scan to email). DISCLAIMER It is your responsibility to work directly with your physician before, during, and after seeking fitness consultation. Thus, any information provided to you should be approved by your physician. Should you choose to use the information without prior consent from your physician you are agreeing to accept full responsibility for your decision.

I have completed the following:

[ ] Application Form[ ] PAR-Q Form[ ] Taken photos[ ] Fitness Assessments and Measurements[ ] Emailed First Month’s Payment to lydia@fithealthy365.com

I am applying for the:[ ] Three Month Commitment ($247.47/month, HST included)[ ] Six Month Commitment ($224.87/month, HST included)[ ] Twelve Month Commitment ($202.27/month, HST included)

Once all items are completed, email the application to lydia@fithealthy365.com. If you have any questions while completing the form, please contact me by email.

I look forward to working with you!

Lydia Di FrancescoCertified Personal TrainerFit & Healthy 365www.fithealthy365.com

Name: _______________________________ Date: __________________ Gender: ____ Age: ____ Date of birth (mm/dd/yyyy): ________________ Address: ____________________________________________________ Email: ______________________________[ ] I consent to receiving the Fit & Healthy 365 blog articles as they are published.[ ] I consent to receiving the Free Monthly Fit & Healthy 365 Newsletter. Phone (Home): ________________ Work: ________________ Cell: _______________ How did you hear about Fit & Healthy 365/Lydia Di Francesco: ______________________________________________________________________

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What do you do for work? _____________________________________________________

Spouse/Kids (names)? ________________________________________________________

Spouse supportive of health and fitness goals? _____________

Fitness

Describe your past or present exercise routine/physical activity: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When were you in the best shape of your life? ________________What did that feel like? __________________________________________________________________________________________________________________________________

Fitness and Health Goals/Objectives:

[ ] Lose Body Fat [ ] Gain Muscle [ ] Improve Health [ ] Improve Nutrition [ ] Improve Flexibility [ ] Improve Endurance [ ] Improve Posture [ ] Motivation [ ] Accountability [ ] More Energy [ ] Other ____________________

Please explain why you have these goals. Ask yourself why at least 3 times to dig deep into your reasons. Which goal is the most important for you right now? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

How long have you been contemplating getting into shape? ___________________________

Have you tried to achieve your goals previously? _____ If yes, what makes this time different? ____________________________________________________________________________________________________________________________________________________

What roadblocks seem to get in the way of success? _________________________________________________________________________________________________________

How committed are you to achieving your goals? (1-not very; 10-totally committed) ________

Rate your ability to perform the following exercises (mark with an “x”):

Exercise Novice Intermediate Advanced Unfamiliar

Squat

Deadlift

Chest press

Row

Shoulder press

Pull-up

Push up

Bicep curl

Lunge

Crunch/Sit-up

Are you currently a member at a gym? Yes [ ] No [ ] If no, please list the gym/workout equipment you have regular access to (eg, stability ball, resistance bands, free weights, etc), if applicable.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How many days a week can you commit to exercising? _________________

(Please provide a realistic number as this affects the type of program I will create) Nutrition

Current daily water intake ___________________Supplements/Vitamins _______________________________________________________Generally, how many times a day do you eat, including snacks? ______________________Do you think you eat too much or too little? Why? ___________________________________Do you eat breakfast? What foods? _____________________________________________Do you snack late at night? What foods? __________________________________________How many meals do you eat in restaurants and/or fast food places per week? ____________Who cooks the food in your household? __________________________________________Other than hunger, what other reasons do you eat?[ ] Stressed [ ] Bored [ ] Lonely [ ] Tired [ ] Happy [ ] Sad [ ] Anxious [ ] Social Events Other: __________________________________

Describe a typical day of eating: ____________________________________________________________________________________________________________________________________________________________________________________________________

If you have any known food allergies, please list them below:__________________________________________________________________________ Are their other foods to which you are sensitive (ie, which cause excessive gas, bloating, congestion)?__________________________________________________________________________

Lifestyle What is the level of activity at your job? None (seated work only) ___________

Moderate (light activity such as walking) _____________High (heavy labor, very active) ____________

How often do you travel (business or pleasure)?Rarely ____ A few times a year ____ A few times a month ______ Weekly _______

Do you drink alcohol? Type? How much? _________________________________________Do you drink caffeine (coffee, tea)? How much? ____________________________________

What is the level of stress in your life? (1-no stress; 10-high stress) ____________What are the top sources of stress? _________________________________________________________________________________________________________________________________________________________________________________________________

Medical and Health Information

Do you have any diagnosed health problems or conditions: ____________________________________________________________________________________________________________________________________________ Are you on any medications that would be affected by exercise:____________________________________________________________________________________________________________________________________________ What, if any, therapies or interventions are being undertaken for your health condition:____________________________________________________________________________________________________________________________________________ Do you have any injuries or “trouble areas”:____________________________________________________________________________________________________________________________________________ Body Composition

Height: _________________ Weight: _________________ Body fat percentage: (if known) _____________________________ • Please send photos of yourself using the guidelines in Appendix A: Self Photo Guidelines. Please provide inches for the following:[See Appendix B: Body Composition Guidelines for picture examples] Chest __________ Biceps (R) ____________ Biceps (L) ________________ Waist (smallest) _________ Waist (belly button) __________ Hips ____________Thigh (R) ________________ Thigh (L) ________________

Fitness Assessment Results (See Appendix C: Fitness Assessment Instructions) Resting Heart Rate: __________________ Pushup Test - Total number of full push ups completed: ______________ Crunch Test - Total number of crunches completed: ______________ Step Test

Heart Rate immediately after test: _____________Heart Rate one minute after test: ______________

Appendix A: Self Photo Guidelines

1. Stand against a bare wall, wearing a small pair of shorts (men) or a swimsuit (women).

2. Set up your camera about 5-7 feet away so that it captures your whole body.

3. Make sure the room is well lit. You may need to use the flash, however, make sure there

isn’t a lot of overhead light; you don’t want to cast shadows.

4. Write down how you took the pictures (ie. camera settings, lighting, how far away the camera was, etc). This will help you duplicate the same conditions in the future.

5. Take four full-body photos: front, left side, right side, and back. Please include your face. I will never publish any photo of you (head showing or not) without your consent.

6. Email to lydia@fithealthy365.com Examples: Women

Men

Appendix B: Body Composition Guidelines

Chest

Biceps R + L Waist

Hip Thigh R + L

Appendix C: Fitness Assessment Instructions Equipment Needed:

● Stopwatch (if you don’t have one your phone probably has a stopwatch feature)● Ruler● Bench or step (a stepstool could work well)

Before starting any of the tests, take your resting heart rate. To do this, find your pulse.

Count the beats for 10 seconds and then multiple that number by 6. When you count, start at zero for the first beat. Record your resting heart rate.

1. Pushup Test

● Perform a short warm up before performing any fitness testing.● Begin in a push up position on hands and toes with hands shoulder-width apart and

elbows fully extended.● While keeping a straight line from the toes, to hips, and to the shoulders, lower your

upper body so your elbows bend to 90 degrees.● Push back up to the start position.● That is one rep.● Continue with this form and complete as many repetitions as possible without breaking

form.● Record the total number of full push ups.

The pushup test is a great way to test your upper body muscular strength and endurance. 2. Crunch Test

● Lie down on your back with your knees bent, feet flat on the floor and your heels about 18 inches away from your behind.

● Place your arms at your sides, palms down, fingertips next to your hips.● Place a ruler next to your fingertips in this position and measure 6 inches further. You

can put a piece of paper, the ruler itself, or a piece of tape at that 6-inch marker.● Keep your hands on the floor throughout the test.● Engage the abs to lift your head, neck, and shoulder blades off the floor● Allow your fingertips to slide toward the 6-inch marker. Return to the starting position to

complete one rep.● Repeat this as many times as you can in 60 seconds, counting only the number of

repetitions that your fingertips successfully reach the 6-inch marker.● Record the total number of crunches.

The Crunch Test measures abdominal strength and endurance. 3. 3-Minute Step Test

● Set up a 12-inch bench or step.● March up and down (up, up, down, down) on the step for 3 consecutive minutes. (It is

very boring… keep going!)● March at a pace of 96 beats per minute. To hear what this sounds like, check out

Metronome Online.● You can rest if you need to, but remain standing.● When 3 minutes are up, stop immediately, sit down on the step, and take your pulse

(count for 10 seconds then multiply by 6). Record this number.● Wait one minute, then take your pulse again. Record this number.

The 3-Minute Step Test measures your aerobic (cardiovascular) fitness level based on how quickly your heart rate returns to normal after exercise.