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Health Questionnaire
Personal Health history
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Name
Your answer
Email
Your answer
Phone Number
Your answer
Sex
Male
Female
Clear selection
height (feet'' inches')
Your answer
Weight (LBS)
Your answer
Date Of Birth
Your answer
Best Time Of Day to Work out
Your answer
Occupation
Your answer
How did you hear about us
Your answer
Please check the box to the left of the condition if you have any of the following:
Heart Disease
Metabolic Disease
High Blood Pressure
Sedentary Lifestyle
Dizziness
Irregular/Accelerated Heart Rate
Irregular/Accelerated Heart Rate
Arthritis/Joint Pain
Musculoskeletal Pain/Injury
Surgery
G.I. Disorder
Pre/Postnatal
Food Allergies
Is your physician prescribing medication for a blood pressure or heart condition?
Other
Pulmonary Disease
Family History of Heart Disease
High Cholesterol
Chest Pain
Shortness of Breath
Osteoporosis
Back Pain/Spine Disorder
Hernia
Hypoglycemia
High Triglycerides
Anemia
Are you over 69 and not used to being active?
Has a physician ever told you that you have a bone or joint problem that will worsen with exercise?
Do you know of any reason why you should not participate in physical activity?
Your answer
How many days a week are you currently working out? (0-7x)
Your answer
How long are your typical workouts? (ie. 30 minutes weights/ 30 minutes cardio, etc)
Your answer
How many days a week would you realistically like to see yourself working out?
Your answer
Describe Your Ideal Personal Trainer (personality, special interests, etc.)
Your answer
What Are Your Fitness Goals? (weight loss, definition, energy gain, etc.)
Your answer
What are your interests? (running, biking, swimming, etc)
Your answer
What is motivating you to exercise with a Personal Trainer? examples: (New year resolution, Dr's recommendation, personal determination..etc..)
Your answer
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