Health & Fitness Questionnaire

Please complete at least 2 days prior to your Consultation. All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and interests safely. Please provide 24 hours notice if you need to cancel or reschedule your appointment.

Date of Brith
Date of Brith
Emergency Contact
Contact's Phone
Contact's Phone
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
Do you frequently have pains in your chest when you perform physical activity?
Have you had chest pain when you were not doing physical activity?
Do you lose your balance due to dizziness or do you ever lose consciousness?
Do you have a bone, joint, or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (ie. diabetes, osteoporosis, high blood pressure, high cholesterol, artritis, bulimia, anemia, epilepsy, respiratory ailments, back problemsm etc. ?)
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Do you take any medications, either prescription or non-prescription, on a regular basis?
Do you smoke?
Do you drink alcohol?
Describe your job
Does your job require you to travel?
is anyone in your family overweight?
Were you overweight as a child?
Fitness History
Have you been exercising consistently for the past 3 months?
Nutrition Related Questions
Do you skip meals?
Do you eat breakfast?
Do you eat late at night?
Do you feel drops in your energy levels throughout the day?
Do you know how many calories you eat per day?
Are you currently or have you ever taken a multivitamin or any other food supplement?
At work or school, do you usually:
Do you do your own grocery shopping?
Do you do your own cooking?
Besides hunger, what other reason(s) do you eat?
Do you eat past the point of fullness?
Do you eat foods high in fat and sugar?
How often do you take part in physical exercise?
Exercise Related Questions
If your participation is lower than you would like it to be, what are the reasons?
What activities are you presently involved in?
At what intensity?
If you could design your own exercise program, what would an ideal training week look like to you?
How can a Personal Trainer help you? Please check that which applies.
In order to increase your chances of being successful at achieving your goals, a certain protocal should be followed. Please ensure all your goals are 'SMART'. S= Specific (Provide details, how long, how much etc.) M= Measurable (How will you measure whether you've reached your goals.) A= Attainable (Be realistic, set smaller goals) R= Rewards-Bases (Attach a reward to each goal) T= Time Frame (Set specific dates for goals)
Where do you rate health in your life?
How committed are you to your fitness goas?
How did you hear about us? Please check that which applies.
Misc Questions
Why did you choose to train with Powerhouse Gym instead of another organization? Please check which applies.