Health and Lifestyle Questionnaire

By admin • January 23, 2008

For those embarking on a personal training program, it is useful for both the trainer, the client and, sometimes, associated medical professionals to have the following information. Fill this form in and take it along with you to your first training session.

Personal Details

Name:
Date of Birth:
Address:
Telephone number:
Mobile number:
E-mail address:
Doctor’s name and practice:
Doctor’s telephone number:
Emergency contact name:
Emergency contact relationship:
Emergency contact telephone number:
Emergency contact mobile number:

Health Questionnaire

Do you have any serious diseases such as asthma, heart problems or diabetes?
Have you ever had any surgery?
Do you suffer from back pain?
Do you have any soreness or tension in a specific area?
Do you experience stiff or swollen joints?
Do you experience fatigue or lack of energy?
Any additional comments?

Lifestlye Questionnaire

Occupation:
How many hours daily do you spend in front of a computer?
How many hours daily do you spend driving?
How active are you?
- a) Fairly active -includes walking and exercise 1 to 2 times weekly.
- b) Moderately active -exercise 2 to 3 times weekly.
- c) Active -exercise 3+ times weekly.
- d) Very active -exercise hard every day.
How many hours do you sleep nightly on average?
Have you ever had a personal trainer? If so, for how long?
Do you have a specific dietary plan?
How do you feel about your dietary habits in general?

Goals

Please list your fitness goals here. They could be anything from fitting into a wedding dress, climbing Everest or just being able to lift yourself into the bath.