Personal Training Personal Training Client Questionnaire If you are interested in personal training at Jack’d Wellness, please fill out the fields below and we’ll be in contact to set up an introductory session. Name Age Gender Phone Number Email Medical Readiness Questions: 1. Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?YesNo 2. Do you feel chest pain when you do physical activity?YesNo 3. In the past month, have you had any chest pain at rest?YesNo 4. Do you ever lose your balance because of dizziness or lose consciousness?YesNo 5. Do you have a bone or joint problem that could be made worse by physical activity?YesNo 6. Is your doctor currently prescribing anything for your blood pressure or heart condition?YesNo 7. Do you know of any other reason why you should not do physical activity?YesNo 8. Do you have or have you ever had any diagnosed medical conditions? If yes, please list.YesNo Please specify: 9. Have you suffered any injuries? If yes, please explain.YesNo Please specify: 10. Have you ever had physical therapy? If yes, please explain.YesNo Please specify: 11. Are you currently on any medications? If yes, please list them.YesNo Please specify: 12. Are you pregnant?YesNo 13. Have you had a recent surgery? If yes, please explain.YesNo Please specify: Lifestyle Questions: 1. What is your current level of exercise? (Please include how often and what type of exercise you currently do). 2. How many hours of sleep do you get in a typical night? 3. How much water do you drink in a day, on average? 4. What is your daily nutrition like? (Please provide examples of what you eat & drink in a day) 5. What do you do for a living? 6. Do you smoke or drink regularly? 7. How would you rate your stress levels on a scale of 1-10? 8. Are you taking any supplements? 9. What is your biggest struggle in maintaining a fitness routine? Fitness Questions: 1. What are some of your short and long-term fitness goals? 2. What type of exercise do you enjoy, or what exercise are you interested in trying? 3. Where do you like to exercise?GymAt HomeOutside 4. How many days per week can you commit to training? (be realistic with your current lifestyle, this can always change) 5. What type of fitness equipment do you have access to? 6. Have you worked with a personal trainer before? If so, what were the results? 7. What do you expect/hope to get out of training? 8. What are some time restrains, distractions, mindset/behaviors, or activities that could slow your progress?
