Personal Training Questionniare

If you have signed up for a Personal Training session please fill out the form below. This will help me understand exactly what you are looking for in your fitness program and it will help us save time during your session.

 

 

Name: *
Address: *
Phone: *
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E-mail: *
Birthdate: *
Occupation *
Emergency Contact Name: *
Emergency Contact Phone: *
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If you answer “Yes” to one or more of the questions below, you must consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.


Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
If you answered yes, please explain:
If you answered yes to any of the above questions, have you consulted a physician regarding increasing your physical activity or exercising? *
If you answered No to the last question will you consult your physician prior to increasing your activity and/or begining a fitness routine? *

Please Check All Conditions That You Have Been Diagnosed With And/Or Take Medication For:


Heart Disease or Stroke
High Blood Pressure
Cancer
Lung/Pulmonary Disease
Kidney/Liver Disease
Ulcer
Gastrointestinal Disease
Depression
Diabetes
Arthritis
Neuromuscular Disease
Arteriosclerosis
Gallbladder Disease
Low back pain within the last 6 months
Psychological Problems
Anorexia
Bulimia
Compulsive Overeating Disorder
Pregnant/Lactating/trying to concieve
Chronic Pain
Which primary physical goal would you like to achieve?
Do you have a specific goal weight, bodyfat or endurance level?
Do you have a date that you would like to achieve these goals by?
Why is this important to you?
On a scale from 1-10, how imortant is this goal to you?
Are there any areas of your body that you would like to improve most?
Have you had any injuries (broken bones, muscle or ligament tears) or past surgeries?
Do you experience any pain while exercising? (if so please state which exercises cause pain)
How hard would you like to be pushed during your trianing session?
Have you ever worked with a trainer before?
If yes, what did you like most about your experience & what would you have changed about it?
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