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?