~PRE-EXERCISE QUESTIONNAIRE FITNESS FIRST ~
Helping you achieve your goals~
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Name: Age: Male Female
Address: P/Code:
Occupation:
Home Phone: Work Phone: Mobile:
Emergency contact: Relationship: Phone:
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Your goals and current exercise habits
Please what you hope to achieve from your exercise program:
To reduce body fat RHR______
To improve aerobic capacity (heart/lung fitness)
To gain some muscle definition
To gain overall fitness
To generally tone up
To reduce stress
Other......
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In order to help you to achieve your goals, please let us knowif you would like us to:
Provide you with personalised service?
Leave you alone so you can train how it suits you?
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To help tailor an exercise program to your specific needs, please answer the following questions concerning your exercise history.
While at school did you enjoy participating in sporting activities? Yes No
If yes, which sports you’re your favourites ? …………………......
Have you been exercising regularly? Yes No
_____ Months _____ Years
If you have been exercising regularly please give details below:
(I) Frequency of exercise - times per week?
…......
(II) Perceived intensity when exercising?
Hard
Medium
Light
Very Light
(III)Time spent exercising?......
(IV) Exercise type or types? ......
`Do you have any negative feelings or have you had any bad experiences with exercise programs? Yes No
If yes, please briefly explain: ………......
......
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Lifestyle and medical considerations. Please answer the following questions with a circle:
Are you taking any prescribed medication? Yes No
Are you currently caring any injury? Yes No
If yes, please briefly explain: ......
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Have you suffered or do you suffer from back pain? Yes No
Do you smoke more than two cigarettes per day? Yes No
Are you pregnant? Yes No
Are you a non-exercising male over 35 or female over 45? Yes No
Do you know your blood pressure? Yes No
If yes, what is it? ____/____
Do you suffer from asthma? Yes No
Do you suffer from diabetes? Yes No
Has anyone in your family under the age of 60 suffered heart disease? Yes No
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Health Screening ( Do not complete this section unless asked by your trainer).
Please indicate with a circle whether you have or have had any of the following:
Gout Glandular fever Any heart condition Sciatica
stroke Rheumatic fever Heart Murmur Arthritis
Asthma Dizziness or fainting High blood pressure Anxiety/Depression
Epilepsy Stomach or duodenal ulcer Chest pain Allergies
Hernia Liver or kidney problems Raised cholesterol Stress Incontinence
Trainer's comments:
……………………......
...... …………………………………………………………………………….
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All information will remain confidential and enables the instructor to modify personalise your program.
I understand that an exercise program has certain risks. I take it upon myself to discuss any changes in my current health with my trainer.
I have to the best of my knowledge provided accurate information regarding my current health status.
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Client Signature ......
Trainer: ...... Date: ...... /...... /......