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Personal Training Client Questionnaire Name Email Address Address City State Zip Code Home Phone Fax # Business Phone Physician's Name Physician's Phone Number & Fax Date of Birth Age Sex Height Weight Weight 1 year ago Weight at 21 years of age
1. Has your doctor ever said you have heart trouble or any cardiovascular problems? yes 2. Do you frequently suffer from pains in your chest? yes 3. Have you ever suffered from a heart attack? yes 4. Do you experience an irregular or racing heart rate during exercise or at rest? yes 5. Do you often feel faint or have spells of severe dizziness? yes 6. Has a doctor ever said that your blood pressure is too high? yes 7. Do you often have difficulty breathing? yes 8. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to? yes 9. Are you over age 65 and not accustomed to vigorous exercise? yes 10. Are you diabetic? yes 11. Are you pregnant? yes
If you answered YES to any of the above questions, written physician approval is required prior to beginning an exercise program. 12. Date of last complete physical examination: Results (Normal): Results (Abnormal): 13. List any medications you are now taking and the reason for which they were prescribed: 14. List any operations you have had (include date): 15. How many times have you visited a physician or any health care professional during the past year? 16. How many days did you miss from work last year due to sickness or injury? 17. Has any member of your immediate family been diagnosed with Heart Disease, Diabetes, Hypertension, Stroke, Obesity or High Cholesterol? Indicate who and age at time of diagnosis. 18. List any member of your immediate family who's had a heart attack before the age of 60. 19. Indicate any of the following, which currently exist or have existed in the past: Anemia, Artery Disease, Arthritis, Asthma, Back Pain/Injury, Bleeding Trait, Bursitis, Cancer, Diabetes, Dizziness, Epilepsy, Headaches, Gout, Heart Murmur, Heart problem, HIV/AIDS, Hernia, High Blood Pressure, Hypoglycemia, Joint Problem, Kidney Problem, Liver Disease, Lung Disease, Phlebitis, Pregnancy, Rheumatic Fever, Serious Injury, Shortness of Breath, Stroke, Ulcer, Varicose Veins, Weight Problems 20. How would you rate your current eating habits? 21. If you are not satisfied, what changes would you make? 22. How much water do you drink per day?
LIFESTYLE 23. Occupation 24. Number of hours worked per week at your job: 25. How do you spend most of your time at work?
26. Do you smoke? yes no 27. Indicate how you are coping with daily stress on a scale of 1-10: 28. Indicate your energy level on a scale of 1-10: 29. On the average, how often do you get 7-8 hours of sleep?
HEALTH RELATED BEHAVIOR 30. How many times per week do you engage in moderate or strenuous exercise for at least 20 minutes? Describe. How long have you been doing this? 31. Have you ever begun an exercise program and then stopped? yes When? Why did you stop? 32. How many times per week do you plan to exercise over the next year? For how long? At what intensity? What times of day are best for you? What days are best for you? 33. What would you like to achieve through participation in a fitness program? 34. In order to match you with the trainer who has the personality and the right experience to help you achieve your goals, please indicate what you are looking for in a personal trainer? 35. What is your favorite activity? How often do you do it? 36. List any other factors which might affect your safe participation in a fitness assessment or fitness program:
I heard about Mind, Body & Soul from: Name of Website, if applicable:
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