Personal Training Activity Assessment Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Birth Date* This field is required.
Month
Day
Year
3
Height & Weight* This field is required.
4
Phone Number* This field is required.
Area Code
Phone Number
5
E-mail* This field is required.
6
Physicians Name & Number
7
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?* This field is required.
YESNO
8
Do you feel pain in your chest when you perform physical activity?* This field is required.
YESNO
9
In the past month, have you had chest pain when you were not performing any physical activity?* This field is required.
YESNO
10
Do you lose your balance because of dizziness or do you ever lose consciousness?* This field is required.
YESNO
11
Do you have a bone or joint problem that could be made worse by a change in your physical activity?* This field is required.
YESNO
12
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?* This field is required.
YESNO
13
Do you know of any other reason why you should not engage in physical activity?* This field is required.
YESNO
14
If you have answered “Yes” to one or more of the above questions, 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.

If you said no on all of the above and we have spoken, click NEXT.
15
What is your current occupation?* This field is required.
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16
Does your occupation require extended periods of sitting?* This field is required.
YESNO
17
Does your occupation require extended periods of repetitive movements? (If yes, please explain.)* This field is required.
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Ok
18
Does your occupation require you to wear shoes with a heel (dress shoes)? * This field is required.
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19
Does your occupation cause you anxiety (mental stress)?* This field is required.
YESNO
20
Do you partake in any recreational activities (golf, tennis, skiing, etc.)? Please explain.* This field is required.
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Ok
21
Do you have any hobbies (reading, gardening, working on cars, exploring, etc)? Please explain* This field is required.
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Ok
22
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? If Yes, Please explain. * This field is required.
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23
Have you ever had any surgeries? Please explain* This field is required.
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24
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)* This field is required.
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25
Are you currently taking any medication? (If yes, please list.)* This field is required.
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26
Please tell me about your past health and fitness, your fitness preferences, health and fitness goals, and any other info about you.
Should be Empty: