Health and Fitness Questionnaire

Pre-Training Questionnaire

Please take a few minutes to carefully fill out this health form and click "submit" at the bottom of the page. For your privacy, the information you provide in response to these questions is strictly confidential. Thank you!

Contact Information

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Birthdate (xx/xx/xxxx) *

Email *

Cell Phone *

Work Phone *

Occupation *

Fitness/Health Goals

Fitness Background

Nutrition/Metabolism

Is there anything else you'd like to accomplish for your fitness and diet with personal training? *

Specific Medical History

Occupation

Do you sit for long periods of time? *

Yes No

Does your lifestyle or work require repetitive movements? *

Yes No

Do you wear shoes with a heel? *

Yes No

Does your occupation/lifestyle cause you anxiety (mental stress)? *

Yes No

Women's Health

Are you pregnant? *

Yes No

If yes, what trimester? If no, have you ever been pregnant? *

Are you currently experiencing or have you gone through menopause? *

Yes No

If yes, please list any concerns you might have: *

Lifestyle

I hereby acknowledge that the information I have provided in this health questionnaire and release form is truthful and correct, and that I have no medical conditions that should prevent me from exercise against the advice of any of my doctors.

I also acknowledge that in respect towards me and my time, my trainer will give at least twenty-four hours notice before canceling my scheduled training session(s). Any changes within that time frame - with the exception of documented family or health emergencies - will result in a complimentary session for me.

I further acknowledge that in respect towards my trainer and his time, I will give at least twenty-four hours notice before rescheduling or canceling my scheduled training session(s). Any changes within that time-frame - with the exception of documented family or health emergencies - will result in a charge ($95) for that session.

Signature (type full name) *

Confirm Birth Date *

Date *