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Personal Training- Questionnaire
*
Indicates required field
Name
*
First
Last
Age
*
Height
*
Current Weight
*
Gender
*
Female
Male
Lifestyle
*
Active
Sedentary
Currently training?
*
No
Yes
Frequency (weekly):
*
1-2
3-4
5 or more
How many times per week would you like to exercise?
*
1
2
3
4
Other
How much time can you devote to each exercise session?
*
30-45 min
1 hour
Other
Where are you planing to exercise?
*
Home, park, beach etc
Gym
Primary areas of interest:
*
Weight control
Strength Increase
Toning
General health
Hypertrophy
Post natal
Increased energy
Other
Where would you like to see the most improvement?
*
Upper body
Lower body
Mid-section
Endurance
Other
Why do you feel you are currently not seeing results?
*
Lack of motivation
Lack of training knowledge
Lack of equipment
Scheduling
Other
Are there any previous injury`s or health concern I should know about?
*
No
Yes
If you answer was yes, please explain
*
10. Have you ever had health problems such as heart attacks, cardiac surgery, chest pains, high blood pressure (over 140/90), smoking problems, high blood cholesterol (more than 200 mg/dl), heart murmurs, arrhythmia, ankle swelling, rheumatic fever, vascular diseases, phlebitis, fainting, shortness of breath, bronchitis, asthma, emphysema, stroke, high blood fat levels, emotional disorders, recent illnesses or hospitalizations, drug allergies, arthritis, and orthopedic problems:
*
No
Yes
Please note that if you answered yes to the above question we will need a written authorization from your physician to start this program
If your answer was yes, please explain
*
Do you smoke?
*
No
Yes
Are you pregnant?
*
No
Yes
N/A
Do you take any medication on a regular basis?
*
No
Yes
If your answer was yes, please list medications and reasons for taking
*
Comments
*
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