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About
Plans
Train
Join
Client Spotlight
Store
Members
PT Questionnaire
Please complete the form below
Name
*
First Name
Last Name
Email
*
What is your current weight?
*
What is your height
*
Birthday
*
Please include the month, day and year.
MM
DD
YYYY
Health Goals
What health goals would you like to achieve in the next 3 months?
Name 3 things you could do in order to improve your health?
Are there any areas of your body that you consider “problem areas”?
*
What are your main reasons for starting a fitness program?
*
General conditioning
Muscular strength
No time
Weight /fat loss
Aerobic fitness
Appearance
Stress management
Flexibility
Improve self-esteem
Other
What is the heaviest you have weighed, and how old were you at that time?
*
Have you ever worked with a personal trainer? If so, provide details:
*
Have you ever done any structured exercise?
*
Yes
No
What type of exercise do you enjoy the most?
If you answered "Yes" to the question above, please explain.
What type of exercise do you dislike the most?
If you answered "Yes" to the question above, please explain.
Describe your current exercise routine, if any.
Lifestyle
What would you say are the main barriers preventing you from exercising?
*
Lack of facilities
No motivation
No time
Injury/illness
Unfit
Appearance
Lack of knowledge
Family
Work
Describe Your Job
*
How many hours do you spend in front of a computer?
On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career.
*
On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your personal life.
*
Do you consider your job physically challenging or active?
*
Yes
No
Are there any other notes about your lifestyle that you would like to share?
Medical History
Have you ever been advised by a physician to avoid any type of exercise?
*
Yes
No
Have you had a major illness or injury in the last 5 years
*
Yes
No
Do you suffer from back pain?
Yes
No
Have you ever had?:
*
a heart attack
cardiac surgery
extreme chest discomfort
high blood pressure (over 140/90)
heart murmurs
ankle swelling
any vascular disease
unusual shortness of breath
fainting spells
asthma, emphysema, or bronchitis
None of the above
Please indicate if you ever experience any of the following symptoms. Do you:
*
Ever get unusually short of breath with very light exertion?
Ever have pain, pressure, heaviness or tightness in the chest area?
Regularly have unexplained pain in the abdomen, shoulders or arm?
None of the above.
Please indicate if you ever experience any of the following symptoms. Do you:
*
Ever have severe dizzy spells or episodes of fainting?
Regularly get lower leg pain during walking that is relieved by rest?
Ever experience palpitations or irregular heartbeats?
Are you currently pregnant or have you given birth in the last 6 months?
None of the above
Do you have tension, numbness or pain in a specific area? Explain.
*
Are you taking any prescription medication?
*
Yes
No
Are there any medical issues which have not been discussed on previous questions?
If your answer is "Yes" to this question or any of the other previous medical history questions, please explain below.
Diet and Nutrition
What previous fat loss, lean muscle gain, or body improvement treatment(s) have you tried? Please state what and when.
*
On a scale of 1-10 (with 1 being poor and 10 being excellent) how would you assess the quality of your eating habits?
*
Diet and Nutrition
Do you?:
*
smoke (and over the age of 35)
drink excessively (more than 1-2/day)
have poor sleeping habits (less than 8 hrs/night regularly)
Would you like any help or advice in changing the quality of your eating habits?
*
Yes
No
I can confirm that I have answered all questions honestly and that the information given is correct.
*
Yes
Thank you!
