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PERSONAL TRAINING QUESTIONNAIRE
Personal Training Questionnaire
Name (First, Last)
What injuries or body aches do you have? If none, type "None".
What medications are you currently taking? If none, type "None".
Have you ever....
...been told by a doctor that you have or have had heart problems, an abnormal EKG, or had a heart attack or stroke?
...had coronary by-pass surgery, angioplasty, or any other type of heart surgery?
...had difficulty breathing or become short of breath with mild or light exertion?
...had a history of diabetes or thyroid, kidney, or liver disease?
...experienced irregular heartbeat or been diagnosed with a heart condition or disease?
Do you currently experience or have any of the following:
Pain or discomfort in the chest or surrounding areas that occurs when you engage in exercise or physical activity?
Shortness of breath with activity or at rest?
Unexplained dizziness or fainting?
Difficulty breathing at night, expect in an upright position?
Swelling in the ankles or lower extremities (other than due to an injury)?
Heart palpitations (rapid or irregular heartbeat)?
Pain in the legs that may cause you to stop walking?
Known heart murmur?
Are you pregnant or is it likely tha tyou may become pregnant at this time?
Have you had surgery, or been diagnosed with any disease in the past three months?
In the past 12 months, have you been told by a healthcare professional that you have an elevated cholesterol level or abnormal lipid profile, or are you on any medications to control your blood lipids?
Do you currently smoke cigarettes, or have you quit within the past six months?
Have your father or brother(s) had heart disease prior to the age of 55 or mother or sister(s) had heart disease prior to age 65?
Within the past 12 months, has a healthcare professional told you that you have high blood pressure?
Do you currently have high blood pressure, or are you taking medication(s) to manage high blood pressure?
Within the past 12 months, have you been told by a healthcare professional that you have an elevated fasting blood glucose level?
Please list any fitness activities that you do regularly (include how often, how hard, and how long).
When is (or do you think would be) the most convenient time of day/days of the week to exercise?
Where is (or do you think would be) the most convenient place for you to exercise?
What are your barriers to exercise? Select all that apply:
Not enough time
Exercise not enjoyable
Lack of results in the past
Not sure what to do for exercise
Not sure how to perform exercises
Not enough energy
What exercise have you tried in the past that you've enjoyed?
What exercise have you tried in the past that you've disliked?
What are your fitness and physical wellness goals?
On a scale of 1 to 10 (10 being ready to start right this second), how ready are you to commit to an exercise program?
Do you understand that the path to your goal won't be a linear process, and there will be ups and downs?
No, help me understand
St. Louis, MO firstname.lastname@example.org
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