Title*

First Name*

Surname*

Date of Birth*

Age*

Occupation*

Sex*

Male

Female

Email Address*

Emergency Contact number*

Do you smoke?*

Yes

No

If yes how many/day?

Do you drink alcohol?*

Yes

No

If yes how many per week?

On average how many hours do you sleep at night?*

On a scale of 1-10 how would you rate your stress level?

0= very low, 10=very high

How would you rate your current health?

0 = worst, 10 = best

Have you fallen in the past 12 months?*

Yes

No

Do you exercise regularly?*

Yes

No

If yes, what and how often?

Do you participate in any sports?*

Yes

No

If yes, what and how often?

Has your doctor ever said you have a heart or lung condition?*

Yes

No

Is your blood pressure?*

Low

Normal

High

Don't know

Has your doctor advised you to limit your physical activity?*

Yes

No

If yes, why?

Do you feel pain in your chest when you exercise?*

Yes

No

Do you have chest pain when you don’t exercise?*

Yes

No

Do you get dizzy, faint, or lose consciousness?*

Yes

No

If Yes, in what circumstance?

Do you get asthma?*

Yes

No

Do you have diabetes?*

Yes

No

Do you suffer from epilepsy?*

Yes

No

Do you have any muscle, bone or joint problems? (e.g. arthritis)*

Yes

No

Details?

Are there other medical reasons not mentioned above that may prevent you exercising?*

Yes

No

Please state:

Do you take any medications - prescription, non-prescription, or supplements – on a regular basis?*

Yes

No

What is it for?

FITNESS HISTORY

How often do you take part in physical exercise?*

0-1 days/week

2-4 days/week

5 or more days per week

On a scale of 1-10, how would you rate your present fitness level?

0 = worst, 10 = best

Have you been exercising consistently for the past 3 months?*

Yes

No

Indicate what exercise you currently perform regularly:

NUTRITION RELATED QUESTIONS

On a scale of 1-10, how would you rate your Nutrition?

1=very poor - 10=excellent

GOAL SETTING

Develop and maintain an optimal level of agility, strength, mobility and fitness through life?*

Yes

No

Improve your current level of fitness?*

Yes

No

Lose body fat?*

Yes

No

Rehabilitate an Injury?*

Yes

No

Increase muscle size?*

Yes

No

Sports specific training?*

Yes

No

Pre-exercise questionnaire

Please complete prior to your initial appointment

FITNESS HISTORY

NUTRITION RELATED QUESTIONS

GOAL SETTING