Personal Training Health and Fitness Questionnaire
Please scroll down to complete the entire registration form.
Date
ex: 06/01/2009
Your answer
First Name
Your answer
Middle Initial
Your answer
Last Name
Your answer
Home Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Mobile Phone
ex: 000-000-0000
Your answer
Other Phone
ex: 000-000-0000
Your answer
Email Address
Your answer
Date of Birth
ex: 01/02/1980
Your answer
Age
Your answer
Weight
Your answer
Height
In inches
Your answer
Parents Names
If under the age of 18
Your answer
In case of emergency notify
Name and best phone number
Your answer
Physician
Your answer
Have you ever been diagnosed with heart trouble?
Do you frequently suffer from pains in you chest?
Do you often feel faint or have spells-of severe dizziness?
Has a doctor ever said your blood pressure was too high?
Has a doctor ever told you that you have a bone or joint problem?
such as arthritis that has been aggravated by exercise, or might be made worse with exercise
Is there a good physical reason that has not been mentioned above?
that would limit your participation in a program of activity in any way
Do you have known elevated blood pressure(>160/95)?
Do you have known elevated cholesterol levels (ratio S or total > 6.2 mmol/L, 240 mg/dl)?
Has a direct blood relative (parent or sibling) had heart trouble prior to age 60?
Do you have diabetes?
If yes, which type?
Your answer
Do you smoke?
If yes, how many cigarettes, cigars or pipes per day?
Your answer
Do you have unaccustomed shortness of breath or shortness of breath with mild exertion?
Do you often wake suddenly from sleep with difficulty breathing?
(paroxysmal nocturnal dyspnea)
Do your ankles swell regularly?
(ankle edema)
Do you or have you ever experienced palpitations, tachycardia or irregular heartbeat?
Did you ever, or do you presently, have a heart murmur
While performing any kind of exercise or work, have you experienced chest discomfort of any kind?
Pain, pressure, or a "squeezing" sensation
Are you aware of any impaired blood flow to your legs?
(claudication)
Do you have any respiratory problems?
Difficulty breathing, asthma, bronchitis, chronic, or reoccurring cough
Do you have any gastro/intestinal problems requiring on-going treatment?
Are you > 25% body fat and male or > 30% body fat and female?
Do you have any muscle, joint or back problems which might be irritated by exercise?
Please check any conditions that apply
Do you have a chronic illness?
If yes, please explain
Your answer
Are you pregnant?
Are you on any medications, including aspirin and cold medicines?
Required
If yes, please include name, purpose and dosage.
Your answer
Have you ever had a graded exercise test?
If yes, what were the results?
Your answer
Do you currently exercise regularly?
Required
If yes, how many times per week?
What duration per session?
Record in minutes
Are you interested in online training?
Record in minutes
What workout equipment do you have access to
Check all that apply
What's are your fitness goals?
Check all that apply
T-Shirt Size
Male (M) and Female(F) Sizes
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