Build Your Child's Exercise Program
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Your Child's Name
(First & Last):
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Your Name:
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Please enter the same e-mail address you
used when you signed up so we can find
your membership.
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Your E-mail Address:
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Blood pressure (if known)
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Medical Conditions (Questions are for your child)
Have you ever suffered from, or do you currently have any of the following?
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Yes No
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Yes No
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Asthma/Breathing Difficulties
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Epilepsy
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Bone or Joint Problems
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Diabetes
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Dizziness or Fainting
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Severe Illness or Injuries
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Chest or Heart Pains
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High Cholesterol
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High or Low Blood Pressure
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Do you smoke?
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If you have answered yes to any of the
above then please give further details:
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Do you take any medication or drugs?
Yes /No (please specify)
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Is there any other condition that might be
reason to modify your exercise program,
or anything else you feel we should know
about? Yes / No (please specify)
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I DECLARE that I have completed the above Pre-Exercise Safety Questionnaire
correctly and to the best of my knowledge and understand that the exercise
program is based on the information given and bpmactive and 45Pounds are not
responsible for any injury or accidents relating to the recommended physical
activities and that I am taking part in physical activity at my own risk. I have also
read and agree to the informed consent form.
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YES NO
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Below are a few more questions that will be very helpful in making your
child the best program possible!
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Resting Heart Rate. This needs to be taken when the child is at their most rested,
usually first thing in the morning before eating. This could just be taken for 15 sec and
multiplied by 4 to get the beats per minute (bpm) reading.
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Waist and Hip measurements. This is to measure the body fat distribution as abdominal and upper body
fat is known to increase health risk. The waist measurement should be taken around the waist, and
around the belly button area. The Hip measurement should be around the widest points. It is essential
that when measuring, the tape is pulled tight enough to keep in position without causing an indentation of
the skin and must be horizontal to the floor. We can then easily assess body composition and body fat
percentage.
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Waist:
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Hip:
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How often do you participate in physical activity?
i.e. enough to get you out of breath for at least 30 minutes
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1 to 2 times per week
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5 to 6 times per week
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3 to 4 times per week
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Not at all
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What types of physical pastimes do you enjoy? (and can do)
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Walking
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Dancing
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Cycling
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Extreme Sports
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Swimming
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Running
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Tennis
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Martial Arts
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Please indicate any other physical
pastimes or sports you enjoy, or give
more details to any of the above:
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Please indicate if you have any negative
feelings towards exercise or if there is
anything you don’t like about exercise or
anything you didn’t enjoy in the past?
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If you have been unable to exercise
regularly, what are the reasons?
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YES NO
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Do you often ‘play’ outside of school either with your friends or family?
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How many hours a day do you watch TV / Play computer games?
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What activities are you participating in
during your leisure time at the moment?
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Please rate your current home and school stress levels on this scale
below from 1 – 5 with 1-no stress at all to 5-very stressful.
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School Stress
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Home Stress
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What makes you feel stressed?
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What do you like to do to
relax and unwind?
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YES NO
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Is altering your weight something that is important to you?
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If you have a target weight, please enter it here:
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If ‘yes’ What is your motivation?
i.e. holiday, health, looking good etc.
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Please enter the numbers that best applies to you at the moment. 1 being the lowest and 5 the highest
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What is your overall level of fitness?
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What is your current level of flexibility?
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What is your current level of
co-ordination?
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What is your current level of strength?
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Minutes per Day Days per Week
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How much time are you able to devote to exercise?
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What are the barriers (if any) that might prevent you from doing exercise?
i.e. school/home work commitments, time/ money/ travel constraints etc.?
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What are your main goals? (Goals need to be Specific, Measurable, Appropriate, Realistic, Time scales)
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Short Term (1-3 months):
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Medium Term (3-6 months)
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Long Term (6-12 months)
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How do you think you would feel when you achieve your goals?
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How best can your family and friends
help you to achieve your goals?
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What obstacles/difficulties could get
in your way to achieve your goals?
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How could the obstacles/difficulties
be overcome?
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Rate these possible outcomes in undertaking your exercise program (rate each one separately):
1 = Not at all important 10 = Extremely Important
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Improve overall health
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Reshape or tone your body
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Improve performance
for a particular sport
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Improve aerobic fitness
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Improve moods and ability
to cope with stress
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Increase strength
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Improve flexibility
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Increase energy levels
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Enjoyment
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Martial
Arts
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Stepping
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Aerobics
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If you own (or have ordered) the 45Pounds Exercise Videos
for Kids, let us know which ones you would like worked
into your child's custom exercise plan. You can also order
these on the next page when you are finished here.
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DONE! Just click on submit and
we'll get started on your program.
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Click Here if you get an error screen when you click on "Submit"
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