Personal Trainers.com - Questionaire


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Personal History Questionnaire

Personal History Questionnaire

The following questions are designed to help Personal-Trainers.com evaluate your personal fitness needs, however, we also recognize and respect your need for privacy. Please feel free to omit any information that you may feel uncomfortable about sharing.

* Indicates Required Field

*First Name

*Last Name

*Address

*City

*Country

*State/County

*Postal Code

*Email

*Telephone

Work Phone

Mobile/Cell

Fax

Age

Gender

Male

Female

Height

Weight

Activity Level

Goals/Aims

Medical Questions

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

Yes
No

Do you feel pain in your chest when you do physical activity?

Yes
No

In the past month, have you had chest pain when you were doing physical activity?

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes
No

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes
No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes
No

Do you know of any other reason why you should not do physical activity?

About Your Trainer

Would you prefer a male or female trainer?

Male
Female
No Preference

Please give a short description of what you require in a trainer

Lifestyle Questions

Occupation

How do you spend the majority of

your time at work?

Do you smoke?	Yes No
	Yes No

If yes, how many per day?

How would you rate your current

How much water do you consume daily?

eating habits?

How would you like to change your current eating habits?

Training Details

How long have you been training?

How often do you train?

How long is each training session?

What time of day do you usually train?

What sports do you participate in?

Do you want your training to be home or gym based?

Gym
Home

Training Goals

Please select one of the training programmes that best describes your goals

Are their any body parts in particular that you wish to train?

Please describe your current knowledge of exercise and weight training

If you have a good knowledge of exercise and weight training, please best describe your current training routine

Areas of expertise
Acupuncture	Aerobics	Aromatherapy
Athletics	Basket Ball	Body Massage
Bodybuilding	Boxing	Canoeing
Cardio	Caving	Chiropractor
Circuits	Core Stability	Cycling
Dance	Dietician	Equestrian
Fencing	Fitness Camps	Fitness Consultant
Flexi Bar Back Xco	Football	Golf
Gp Referral	Gym Stick	Gymnastics
Hang Gliding	Health Club	Hockey
Juvenile	Keep Fit	Life Coach
Lifestyle Consultant	Marathon	Martial Arts
Meditation	Motor Sports	Mountain Expedition
Nutrition	Outdoor Work	Personal Trainer
Physiotherapist	Pilates	Pre Post Natal
Reflexology	Resistance Training	Rock Climbing
Rowing	Rugby	Running
Senior Citizens	Skiing Snowboarding	Skydiving
Soccer	Sports Injury	Sports Massage
Step	Strongman Training	Swimming
Swiss Ball	Tai Chi	Tennis
Triathlon Iron Man	Vibration Training	Weight Lifting
Weight Management	Weight Training	Yoga
Youth Obesity	Other:

Terms and Conditions

Personal-Trainers.com shall have no liability for any injury, illness or similar difficulty that arises out of or connected with any instructions or guidance provided by any personal trainer provided by us.

Personal-Trainers.com assumes you have had medical clearance and doctors consent to participate in an exercise program. You must agree that you assume the risks associated with any and all activities and/or exercises in which you participate.

I accept the above terms and conditions

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