PERSONAL TRAINING 

SCREENING QUESTIONNAIRE

Name:_______________________________________   Date:______________________

Age:____    Phone:________________________

Person to Contact in Case of Emergency

Name_________________________ Relationship___________ Phone________________

Level of Activity:    ___Sedentary     ___Mildly Active     ___Active      ___ A Jock!

Regular Activities: ___________________________________________________________

____________________________________________________________________________

Measurements:

Height____  Weight____    Arm____  Thigh____ Calf____ Chest____  Waist_____  BodyFat %____

Typical Meals (include amounts):

Breakfast____________________________________________________________________

Lunch ______________________________________________________________________

Dinner______________________________________________________________________

Snacks_______________________________________________________________________

Supplements (pills, shakes, etc)__________________________________________________

Have you ever tried any "diets?" ______   If so, what results?________________________

List any medications/drugs you are taking. _______________________________________

Do you now, or have you ever had:  

                                                                                                                                                                                                          Yes    NO     

1. History of heart problems, chest pain or stroke.                                                  ___     ___

2. Increased blood pressure.                                                                                       ___     ___

3. Any chronic illness or condition.                                                                           ___     ___

4. Difficulty with physical exercise.                                                                           ___     ___

5. Advice from Physician not to exercise.                                                                 ___     ___

6. Recent surgery (within past year).                                                                        ___     ___  

7. History of breathing or lung problems.                                                                ___     ___

8. Muscle, joint or back disorder.                                                                             ___     ___

9. Diabetes or thyroid condition.                                                                               ___     ___

10. Smoking habit.                                                                                                      ___     ___

11. Obesity (> 20% over ideal bodyweight)                                                             ___     ___

12. High alcohol intake.                                                                                             ___     ___ 

13. Increased blood cholesterol.                                                                                ___     ___ 

14. Family history of heart problems.                                                                       ___     ___

15. Hernia or condition that may be aggravated by lifting weights                       ___     ___

 Please feel free to elaborate on any of the above or anything else we should know about.

____________________________________________________________________________

____________________________________________________________________________

What are your goals?_____________________________________________________

How would you rate your weight-training knowledge/experience? 

 ___None     ___ A little      ____ A lot       ____ Gym-rat 

What are your available training times? ___________________________________