Fitness Questionnaire

The following questions are designed for the purpose of reviewing and determining your health history, possible risk factors, fitness and activity level, attitude and lifestyle. We recommend that anyone starting an exercise program should consult with a physician prior to starting.

Personal Health & Medical Information

* Indicates required field

Date *

Name: First, Last *

First

Last

Gender *

Female Male

Date of Birth *

Email *

Phone *

Height *

Weight *

BMI *

Blood Pressure *

Resting Heart Rate *

Contact in case of emergency: *

Phone *

Relation *

Cardiovascular Risk Factors

Existing Medical Conditions

Are you currently pregnant? *

Have you given birth within the last year? *

Are you currently taking any medication? *

If so, please indicate the medication and for what condition: *

Do you have any allergies? *

If yes, please indicate to what, and if medication is required: *

Injuries

If Other Injury, please specify: *

During the past two years, have you visited a chiropractor, physiotherapist, massage therapist, occupational therapist, or any other health therapist? If yes, please list. *

Do you have any injuries or health concerns that effect you on a daily basis? *

Do you have any other health conditions or considerations that are not mentioned? *

In the past 12 months have you been advised by a doctor not to exercise? *

No Yes

If yes, please give details: *

Occupation and Leisure Information

Current occupation, and previous occupation if less than 2 years *

On a scale of 1-10, how stressful do you feel is your job? *

How many hours a day do you work on average (outside of the home)? *

If you walk or cycle to work, what method do you use and how long does it take? *

If you take transportation (car, bus etc) to work, how long does it take? *

How would you describe your physical activity level while at work? *

Please describe your home and family life (married, divorced, single, kids, pets etc), including any items that could potentially add to your stress/workload (educational courses, kids activities, spouse works a lot, etc), and those that can help reduce it (social activities, etc): *

How would you describe how well you deal with stress (well, not well etc), and what methods you use to try to deal with it (eating, yoga, wine etc.): *

Outside of work, how active would you describe yourself: *

Other activity level: *

How many hours of sleep do you get a night? *

Is it restful sleep? *

If it is not restful sleep, are there specific factors inhibiting your sleep (pain, stress, snoring spouse etc.)? *

Current and Past Fitness Information

How would you describe your current fitness level? *

If you participate in formal exercise, please list the types (running, yoga, tennis, weight training etc) *

If your current fitness level is different than a past fitness level, please describe the change and the reasons for it: *

What are your fitness expectations over the next several months (level improvements, specific goals etc.) *

Have you ever worked out with a personal trainer before? *

Do you have any specific concerns that you feel may impede your fitness goals (time, motivation, spouse concerns, ability etc.)? *

Do you have any specific fitness or health goals you would like to work towards? Goal #1 (inc. timeline): *

Goal #2 (inc. timeline): *

Dietary Habits and Information

How knowledgeable do you feel you are about nutrition? *

How often do you feel you make healthy nutritious choices for yourself? *

What are your favourite things to eat that you consider healthy? *

What are your favourite things to eat that you consider unhealthy? *

Are you taking any supplements (e.g. vitamins, minerals, antioxidants, herbal remedies)? If yes, please list. *

How many alcoholic beverages do you consume in a week? What kinds? *

Do you smoke? If so, how many cigarettes a day? *

Do you have weight loss as a goal? *

If so, how much would you like to lose? *

Have you had any weight fluctuations in weight in the last 12 months? If so, are you aware of the reasons why? *

Have you ever lost a significant amount of weight in the past? *

Client Acknowledgment

By submitting this form I certify that I have fully disclosed all pertinent information in an honest and truthful manner: *

Yes No

Health Questionnaire