Professional Documents
Culture Documents
QUESTIONNAIRE
PERSONAL DETAILS
MEDICAL DETAILS
NAME & LOCATION OF CLINIC ________________________________________________
If you have any pre-existing or medical conditions, I recommend that you discuss your exercise intentions with your
doctor.
Have you discussed your exercise intentions with the General Practitioner? YES OR NO
1
MEDICAL PROFILE
YES//NO Have you ever had a heart attack, coronary surgery or a stroke?
YES//NO Has your doctor told you that you have heart trouble, vascular disease or heart murmur?
YES//NO Do you suffer from pains in your chest, especially during exercise?
YES//NO Do you ever get pain in your calves, buttocks or at the back of your legs during exercise
which are not due to soreness or stiffness?
YES//NO Do you ever feel faints or have severe dizziness, particularly during exercise?
YES//NO Do you suffer from swelling in your ankles?
YES//NO Do you ever get the feeling that your heart is suddenly beating faster, racing or skipping
beats, either at rest or during exercise?
YES//NO Do you have chronic obstructive pulmonary disease, interstitial lung disease or cystic
fibrosis?
YES//NO Have you had an attack of shortness of breath that developed when you were not doing
anything strenuous, at any time in the last 12 months?
YES//NO Have you been woken at night by an attack of shortness of breath at any time in the last 12
months?
YES//NO Do you have diabetes and if so what type? Type 1 or Type 2 (please circle)
YES//NO If yes, is your diabetes under control?
YES//NO Do you have any ulcerated wounds or cuts on your feet that do not seem to heal?
YES//NO Do you have any liver, kidney or thyroid disorders?
YES//NO Are you, or do you have reason to believe, that you may be pregnant?
YES//NO Is there any other physical or medical reason, or are you taking any medication which could
prevent you from undertaking an exercise program ie: cancer, osteoporosis arthritis, epilepsy,
asthma, mental illness, gastric banding?
IF YES PLEASE PROVIDE DETAILS:
YES//NO Do you smoke on a daily basis; if so how many would you smoke per day?
YES//NO Did you quit smoking in the last 2 years?
YES//NO Do you have a close relative who has had a stroke, heart attack or suffered from
cardiovascular disease?
IF YES WHAT RELATION WAS THIS PERSON TO YOU?
AT WHAT AGE WERE THEY WHEN DIAGNOSED?
DID YOUR RELATIVE DIE SUDDENLY AS A REULTS OF STROKE OR HEART ATTACK?
YES//NO Have you experienced menopause before the age of 45?
IF YES DO YOU TAKE HORMONE REPLACEMENT MEDICATION?
YES//NO Has your doctor ever told you that you have high blood pressure?
YES//NO Have you recently had your blood pressure checked?
IF YES WHAT WAS YOUR BLOOD PRESURE?
YES//NO Have you recently had a cholesterol test?
IF YES,
WHAT WAS YOUR SERUM CHOLESTEROL LEVEL?
WHAT WAS YOUR SERUM HDL LEVEL?
WHAT WAS YOUR SERUM TRIGLYCERIDE LEVEL?
YES//NO Have you been seriously ill in the last 12 months?
IF YES PLEASE PROVIDE DETAILS:
2
Describe any injuries you have in the past:
Please circle any of the following areas where you have a physical injury or weakness:
Are there any other medical/exercise issues that you wish to share with me even if it is not directly related
to your participation in exercise (eg: allergies)
_____________________________________________________________________________________
_____________________________________________________________________________________
GOAL SETTING
1. What is your motivation for choosing to exercise with a personal trainer
_______________________________________________________________________________
_______________________________________________________________________________
2. Please circle the following, that you wish to improve through fitness:
3
STRENGTH FLEXIBILITY INCR CARDIOVASCULAR FITNESS OVERALL HEALTH
6. In order for me to support you I will need to keep in contact with you during the week, how may I
best do this to keep you motivated and on track?
PHONE EMAIL TEXT
INDEMNITY STATEMENT
I recognise that RoadMap to Fitness is not able to provide me with medical advice in
regards to medical fitness and that this information is used as a guideline to the
limitations of my ability to exercise. I have to the best of my knowledge provided
accurate information regarding my current health status. I agree that my trainer shall
not be liable for any loss, damage or injury to myself or my property suffered as a
result of exercise or other activity, whether directly or indirectly arising out of any act
or omission by my trainer. I acknowledge sole responsibility for any personal
equipment. I consent to receive medical treatment, which may be deemed necessary
in the event of injury, accident or illness.