Medical & Fitness Questionnaire
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Phone Number
*
Format: 00000000000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Your Health
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
In the past month, have you had a chest pain when you were not doing physical activity?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing medication for your blood pressure or heart condition?
*
Yes
No
Do you know of any other reason why you should not take part in physical activity?
*
Yes
No
Are you disabled? if yes please state if you need additional assitance.
Yes
No
Other
Fitness History
What type of activities are you currently involved in?
How often do you train per week?
Have you been exercising consistently for the past 3 months?
When were you the best shape of your life?
How many hours a night do you sleep?
Do you smoke?
Yes
No
Socially
Do you drink alcohol?
Yes
No
Socially
If your participation is lower than you would like it to be, what are the reasons?
Lack of time
Illness/Injury
Lack of motivation
Other
Goals Setting
Why are you interested in Personal Training?
What are your fitness goals and when would you like to achieve them?
Would you say that your job is stressful?
Yes
No
What does a typical training week look like and What type of training are you currently doing?
What is your current diet? What types of foods are you eating on a dailyweekly basis?
What has worked in the past and What do you enjoy doing in the gym?
How do you cope with stress?
Do they have support outside? What do their partner / family / friends / support group think of them wanting to achieve this goal?
What current factors are stopping you starting Personal Training? Time/Money/Family/Work/motivation etc?
Nutrition Related Question
Do you eat breakfast?
Yes
No
How do you rate your nutrition?
Good
Bad
Room for improvement
Other
How many times a day do you eat?
Do you skip meals?
Yes
No
Other
Do you eat late at night?
Yes
No
Other
Do you experience drops of engird during the day?
Yes
No
Other
How many litres of water do you drink?
How many calories do you consume during the day?
If you are hungry what is your go to food?
What do you typically eat on a daily basis?
Do you eat foods high in fats and sugar?
Yes
No
Other
How many times a week do you eat out?
Yes
No
Other
Do you do your own cooking?
Yes
No
Other
Are you currently or have you ever taken muliti vitamins or supplements? If yes what type?
Yes
No
Other
Informed Consent
I confirm I am participating in the activity voluntarily and that I understand I can withdraw my consent and participation in the activity at any time, for any reason.
*
Yes
Signature
*
Are you under 16? If yes, can your parents please give their consent below .
Yes
No
Signature
Submit
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