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My Journey
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Questionnaire
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YOUR CART
Personal Training
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Name & Phone #
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What do you want to get out of working with a trainer?
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How many times per week do you exercise?
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0-1
2-3
4-7
How long have you been regularly exercising?
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What type of training do you see yourself doing?
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Functional
Cardiovascular
HIIT
Strength
Athletic
Other
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Health History
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Do you have any physical injuries or disabilities or limitations that must be addressed before developing an exercise program?
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Has your doctor ever said you have a heart condition and recommend only medically supervised physical activity?
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Health History
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Coronary heart disease, angina, heart surgeries
Congestive heart failure, heart attack, pacemaker
Asthma, COPD, or trouble breathing
Chronic bronchitis or emphysema
Diabetes (Type 1 or 2)
High blood pressure (140/90 or higher)
High blood cholesterol (220 or higher)
Smoker (Active or Non-Active)
Dizziness or fainting
Osteoporosis or other bone problems
Currently pregnant or planning to be
Family hsitory of cardiac or pulmonary disease before the age of 55
Thyroid conditions
Signs of stroke or TIA
Fibromyalgia
Eating disorders
Cancer
NONE
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