NEW CLIENT APPLICATION
Health & Lifestyle questionnaire for Personal Training applicants
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Email *
Full name *
Date of birth *
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Gender *
Height (ft in) *
Weight (KG) *
Email address *
Telephone number *
Please list your specific goals (i.e amount of weight loss, % of bodyfat loss, amount of lean muscle gain etc) *
If you have any, what are your specific time frames for achieving your goals? *
Please select which type of progress is the most important for you: *
What is your fitness/strength training experience? *
Do you currently train at least 3 times per week? *
Please describe your current physical activity (weekly) *
If you are not currently training at least 3 times per week, have you ever been on a consistent exercise programme (more than 3 times per week)? *
If you have previously exercised on a consistent basis, how long ago was this, and how long did it last?
Are you willing to exercise for at least 3 hours per week? *
Do you have a gym membership? If not, are you willing to get one? *
If you are planning to train mostly from home, please list in detail the equipment you have available
Are you willing to spend at least 30 minutes each day preparing your meals? *
If you have any diagnosed medical conditions, please list your conditions
If you are currently on any medication(s), please list them. This includes the contraceptive pill
What additional therapies or interventions are being undertaken for the given health problem(s)?
Please list any current and/or previous injuries
What additional therapies or interventions are being undertaken for your current/old injuries?
Do you smoke? *
If the answer is yes, how many do you smoke each day?
Do you drink? *
If the answer is yes, how many units do you drink each week? 175ml of wine is 2 units, 1 pint of beer/lager is 3 units *
What do you do for a living? *
What level of physical activity is required for your job? *
Does your job involve shift work? *
If you follow a more regular schedule, do you work mornings, days, or nights? *
How often do you travel? *
Do you have children? *
Please indicate the physical activities you participate in outside of the gym and outside of work *
How many times do you go food shopping per week? *
How many times do you eat out per week (includes restaurants and takeaways)? *
How much money do you spend on supplements per month? *
Do you have any allergies?
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If yes, please list them
Do you suffer from heart burn? *
Do you suffer from gas or belching? *
Do you suffer from constipation? *
Do you suffer from diarrhoea? *
Are there any foods that make you feel uncomfortable after eating them, if any (please list)?
Do you have a sense of fullness after meals? *
Do you suffer from bloating 1 hour after eating? *
Do you have less than 1 bowel movement per day? *
Do your muscles become easily fatigued? *
Do you suffer from aches and pains in your joints? *
Do you suffer from arthritis? *
Do you suffer from stiffness or limitation of movement? *
Do you suffer from pains or aches in muscles? *
Feelings of weakness or tiredness? *
Do you suffer from headaches? *
Do you suffer from dizziness? *
Do you suffer from chest congestion? *
Do you suffer from asthma or bronchitis? *
Do you suffer from a shortness of breath? *
Do you suffer from difficulty breathing? *
Do you suffer from frequent illness? *
Do you suffer from frequent or urgent urination? *
Do you suffer from acne? *
Do you suffer from hives, rashes or dry skin? *
Do you suffer from hair loss? *
Do you suffer from flushing, hot flashes? *
Do you suffer from excessive sweating? *
Do you suffer from an irregular or skipped heart beat? *
Do you suffer from a rapid or pounding heartbeat? *
Do you suffer from chest pain? *
Do you suffer from poor memory? *
Do you suffer from mood swings? *
Do you suffer from anxiety, fear or nervousness? *
Do you suffer from anger, irritability or aggressiveness? *
Do you suffer from depression? *
Do you suffer from binge eating? *
Do you suffer from craving certain foods? *
Do you suffer from excessive weight gain? *
Do you suffer from compulsive eating? *
Do you suffer from water retention? *
Do you consider yourself underweight? *
Do you suffer from fatigue and sluggishness? *
Do you suffer from apathy, lethargy? *
Do you suffer from hyperactivity? *
Do you suffer from restlessness? *
Do you have trouble falling asleep at night? *
Do you have difficulty waking up in the morning? *
Do you sleep for less than 7-8 hours each night? *
Do you wake up once or more during the night? *
Do you struggle to fall asleep? *
Do you sleep in a room with any light or noise? *
In your opinion, what has stopped you from achieving results in the past? *
Any other information
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