Clone of Personal Training Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

3

Email* This field is required.

example@example.com

4

Phone Number* This field is required.

Area Code

Phone Number

5

Preferred method of communication

6

How did you hear about me?* This field is required.

7

What is your current age?

8

What is your current height, weight, and body fat (if known)?

9

What is your occupation?

10

Which class days/times would you like to join?

11

Fitness Related Questions

12

How often do you currently participate in active exercise?* This field is required.E.g. biking, running, swimming, lifting, etc

1-2 times a week

3-4 times a week

5-7 times a week

not in the last 3-6 months

13

How many hours do you spend participating in active exercise each day?This is purposeful and planned exercise

Fewer than 30 min

1-3 hours

30 min to 1 hour

3-5 hours

5-7 hours

More than 7 hours a day

14

Approximately how many hours a week do you do other types of physical activity?E.g. housework, walking to school/work, home repairs, gardening, etc

Fewer than 5 hours

10-14 hours

5-9 hours

15-19 hours

20 or more hours

15

How many hours of sleep on average do you get per night?

16

How would you rate the overall quality of your sleep?

17

How would you rate your overall energy throughout the dayAwake and alert, dragging and needing caffeine, etc

18

How would you rate your overall stress level?

19

Do you have any joint pains, aches, joint injuries, or limitations?* This field is required.

YESNO

20

If yes, please describe.* This field is required.

21

Is there anything else you would like your coach to know?This can include anything that may affect your ability to complete your program or ways to help you stay motivated!

22

Physical Activity Readiness Questionnaire PAR-Q

23

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YESNO

24

Do you frequently have pains in your chest, when you perform physical activity?

YESNO

25

In the past month, have you had any pains in your chest when you were not doing physical activity?

YESNO

26

Do you lose your balance owing to dizziness or do you ever lose consciousness before, after, or during physical activity?

YESNO

27

Do you have any bone or joint conditions that may affect your exercise program?E.g. diabetes, epilepsy, back problems, respiratory ailments, etc

YESNO

28

Do you have any other medical condition that may affect your exercise program?Please explain below

29

Have you been hospitalized in the last 6 months?

YESNO

30

Have you had recent surgery?

YESNO

31

Are you trying to get pregnant, are pregnant, or given birth in the last 6 months?

YESNO

32

If you answered "YES" to any of the above, please give more specific details (if not already explained above).

33

Right now, are you taking any medications, either over-the-counter or prescription? Please list the medication and what it is for.

34

Client Signature* This field is required.Please type your name below indicating all of the answers provided are honest and complete.

35

Thank you for taking the time to complete this questionnaire. It may give you an error message after you hit submit but I do receive your competed form. Your information will make it easier to design a program that suits your needs, fits your lifestyle, and includes activities that you enjoy! I will also know how to support you, should obstacles arise.

Nicole Pomerenke

Certified Personal Trainer

Certified Nutrition Coach