GET PHYSICAL Pre Exercise Questionnaire

1
Name* This field is required.
First Name
Last Name
2
DOB* This field is required.
Date
Month
Day
Year
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
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Aruba
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The Bahamas
Bahrain
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Benin
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Bhutan
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Dominican Republic
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Ethiopia
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Ghana
Gibraltar
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Guatemala
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Guinea
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Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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North Korea
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Kosovo
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Have you had a Personal Trainer before?* This field is required.
YES
NO
7
If yes, please specify who and when..
8
Did you get the results you wanted?* This field is required.
YES
NO
9
Why or why not. Tell me about your experience..
10
Are you currently doing any exercise?* This field is required.
YES
NO
11
If YES please specify..
12
What’s your favourite training style?
E.g H.I.I.T, strength training, cardio, etc.
13
What has been your biggest challenge so far?
(Time, motivation, knowledge, injuries, etc.)
14
What type of support are you looking for from a coach?* This field is required.
Accountability
Motivation
Nutritional guidance
Structured program
Injury rehabilitation
Other
15
3 Months
16
6 Months
17
12 Months
18
What are your current fitness goals? (Select all that apply)* This field is required.
Lose Weight
Gain muscle
Upcoming Event
Increase strength
Increase endurance
Lose fat
General Fitness
Other
19
Do you have ANY medical conditions listed below or other that may implicate your training?* This field is required.
Smoke
Diabetes
Faint
Spasms
Epilepsy
Muscle Injuries
Stroke
Surgery
Migraine
Medication
Asthma
Joint Injuries
Pregnancy
Been Pregnant
Back Injuries
Arthritis
Heart Problems
Hepatitis
High Blood Pressure
Low Blood Pressure
20
Specify for the above or other..
21
Are you currently on any medications? If so please disclose which ones..
22
In just a few words describe your current physical condition..
23
How many days a week can you commit to training?* This field is required.
24
How long can you set aside for each training session?* This field is required.
25
Monday
5:00am - 12:00pm and 1:00pm - 8:00pm
26
Tuesday
5:00am - 12:00pm and 1:00pm - 8:00pm
27
Wednesday
5:00am - 12:00pm and 1:00pm - 8:00pm
28
Thursday
5:00am - 12:00pm and 1:00pm - 8:00pm
29
Friday
5:00am - 12:00pm and 1:00pm - 8:00pm
30
Name* This field is required.
First Name
Last Name
31
Phone Number* This field is required.
Please enter a valid phone number.
32
Suburb
33
Relationship to you
34
Specialist Name & Number (eg. Doctor, Chiropractor, Sports Therapist, Sports Coach)
35
Signature* This field is required.
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36
Date* This field is required.
Date
Month
Day
Year
37
Signature* This field is required.
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38
Date* This field is required.
Date
Month
Day
Year
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