Personal Training Health Screening Questionnaire
Personal Information
Today’s date: {sign_date}
Title: Dr. Mr. Mrs. Ms.
Name: {name} Birthdate: {dob} Age:
Address: {address}
Email:
Phone:(home) {phone}
Phone:(work)
Phone:(cell)
Fax:
Occupation:
Gender: Male Female Height: Weight:
Person to contact in case of emergency: {contact_name}
Tel: {contact_phone}
Physician’s Name:
Tel:
May I send a copy of your consultation to your physician &/or physical therapist?
Yes No
Medical History
Please indicate if any of these statements apply to you by placing a YES in the space provided (*past or current):
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History of heart problems (ie. chest pains, heart murmur, or stroke)
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Diabetes Mellitus
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Asthma, breathing or lung problems
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Allergies
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Cancer (other than skin)
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Seizures, seizure medication, neurological problems or dizziness
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High blood pressure
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Back problem, joint or muscle disorder still affecting you
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Recent surgery (last 12months)
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Hernia or any condition that may be aggravated by exercise
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Physician’s advice not to exercise
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History of high cholesterol
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Family history of coronary heart disease?
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Do you smoke tobacco products?
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Do you consume alcohol?
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Do you take supplements of any kind?
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Are you on medication?
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Do you have a joint problem that might be aggravated by exercise?
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Is stress from daily living an issue in your life?
Skeletal Injuries
Back
Neck
Head
Knee (R, L)
Shoulder(R, L)
Other Injuries:
Surgery:
Please describe any special considerations or how your injury currently affects your ability to function: (i.e. Illness or injury)
Please talk with your doctor by phone or in person before you start any new training program or have a fitness appraisal. Tell your doctor about your health questionnaire and which questions you answered yes.
Goals
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What are your concerns and goals? (examples: fat loss, strength, power, muscular endurance, cardio fitness, flexibility, agility, core stability or balance)
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Why do you want to achieve these goals? (examples: general health, injury prevention/rehab, sport-specific training, aesthetic reasons)
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Which criteria will you use to measure the effectiveness of this program? (examples: body measurements/%, sport-specific goals, increased energy level, stress reduction)
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What areas do you want to concentrate on or emphasize? (i.e.: specific areas to strengthen, joint stability, cardio or core conditioning, specific areas to mobilize).
Fitness History
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How long has it been since you have exercised regularly? (2 or more times/week).
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Do you have experience with free weights or functional stability training?
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What type of cardiovascular exercise are you familiar with?
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If you are an experienced exerciser or athlete, what exactly is your current
Program?
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Are there any exercises that are contraindicated or not recommended by your physician or physical therapist?
Lifestyle
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How would you describe your level of daily activities?
Light(office work) Moderate(manual labor) Heavy(construction)
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Stress (high=5,low=1)
Physical 1 2345
Personal/Emotional 1 2 3 4 5
Mental/Career 1 2 3 4 5
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Present method of handling stress:
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Number of hours of sleep per night?
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What is your available time and frequency for exercise?
What days: M T W Th F
What times: Is pm
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Any special considerations or requests?
Date: {sign_date}