Personal Training Questionnaire

First Name Last Name

Address

Address 2

City State Zip Code

Phone (home) Phone (work)

E-mail

Personal Information

Height (example 5'8") Weight Age Male(M) / Female(F)

Medical History

Allergies Abnormal Sleeping Patterns Arthritis, Bursitis Back Pain (low, mid, neck) Cancer Chest Pain Diabetes Elevated Cholesterol Embolism (Blood Clot) Heart Disease (Heart Attach, Murmur) Head Aches/Fainting Joint Injuries Liver Disease Lung or Respiratory Disease Muscle Cramps/Spasms Operations/Surgeries Pregnancy Stroke

If you answered yes to any questions, please explain.

Are you currently taking any medications?

Lifestyle

How do you characterize your lifestyle?

How active do you consider your everyday lifestyle?

How do you describe your nutritional habits?

Please indicate your goals for this exercise program. (Check all that apply)

Improve Strength Improve Flexibility Improve Cardiovascular Fitness Improve Athletic Performance Improve Muscle Tone Rehabilitate Injury Lose Weight / Inches Gain Weight / Inches Injury Prevention Reduce Stress Increase Energy

Any Additional Areas?

Are you presently involved in an exercise or sports program? Yes No

Explain?

How do you catagorize yourself (knowledge of exercise)?

Please indicate the primary location of your workouts.

Indicate exercise equipment available to you. (example - selectorized machines, free weights, treadmills, dumbbells, etc.)

How many days a week will you be able to exercise?

How much time to you have set aside to exercise? (in minutes)

Briefly state any additional information that might help us design your exercise program. (favorite exercise, least favorite exercises, etc.)

Anyone starting an exercise program should always consult with their physician. By submitting this information you agree to release Elite Strength from any liability.