Health and Lifestyle Questionnaire

Name (required)

Primary Phone (required)

Email (required)

Date of Birth (required)


When was the last time you had a physical examination?:

Have you had your cholesterol checked within the past year? Results?
YesNo

Are you currently on any medications?
YesNo

Has your doctor ever diagnosed you as having heart disease, stroke, diabetes or epilepsy?
YesNo

Has a parent, brother, sister ever been diagnosed with heart disease?
YesNo

Do you have any back problems, arthritis or any orthopedic problems?
YesNo

Any other medical concerns?
YesNo


Have you ever used a personal trainer before?
YesNo

What is your current activity level? Per week

Do you smoke? How much?
YesNo

Do you consume alcoholic beverages? How much per week?
YesNo

How much caffeine do you consume in a day?

How much water do you drink in a day?

Do you eat breakfast? 
YesNo

Describe your stress level

What motivated you to consult with a personal trainer?

What are your goals? What do you hope to accomplish by working with a trainer?
Improve body compositionDecrease body fatTone and firmDefine musclesIncrease muscle massReduce stressImprove flexibilityIncrease energyImprove nutritionImprove overall healthTrain for an event

Short Term Goals:

Long Term Goals

What types of exercise do you like to do?

What types don’t you enjoy?

How often do you plan on exercising?

What are you biggest obstacles which may prevent you from achieving your goals?

What day(s) off would you prefer?

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