Personal Training Fitness Assessment Page 3
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5UMass Campus Recreation & Sport Clubs
112 Recreation Center
161 Commonwealth Avenue
Amherst, MA 01003
(413) 545-0022 (phone)
(413) 577-3870 (fax)
FITNESS ASSESSMENT QUESTIONNAIRE AND WAIVER
Please answer all questions accurately and honestly to allow us to fully determine your individual needs.
Date __________________
First Name__________________________________________ Last Name______________________________________________
Address__________________________________________________ City ______________________ State ____ Zip ___________
Home Phone________________________________________
Business or Alternate Phone________________________________
Age___________________ Height____________________
Weight______________________
For questions 1-9, have you experienced:
1. Pain or discomfort (or anginal equivalent) in the chest, neck, jaw, arms, or other areas
that may be due to ischemia (decreased blood flow)
YES
NO
UNSURE
2. Shortness of breath at rest or w/mild exertion
YES
NO
UNSURE
3. Dizziness or syncope at rest or w/mild exertion
YES
NO
UNSURE
4. Orthopnea/paroxysmal nocturnal dyspnea (shortness of breath) at rest or w/mild exertion
YES
NO
UNSURE
5. Edema (excessive accumulation of tissue fluid)
YES
NO
UNSURE
6. Palpitations or tachycardia (sudden rapid heart beat)
YES
NO
UNSURE
7. Intermittent claudication (lameness due to decreased blood flow)
YES
NO
UNSURE
8. Known heart murmur (abnormal heart sound)
YES
NO
UNSURE
9. Unusual fatigue or shortness of breath with usual activities
YES
NO
UNSURE
10. Do you smoke?
YES
NO
11. Do you drink occasionally?
YES
NO
12. Have you been a member of a health club before?
YES
NO
13. Have you been exercising regularly for the past 6 months?
YES
NO
14. Please rate your exercise level on a scale of 1 to 5 (5 indicating very strenuous) for each age range through your present age:
15-20_____
21-30_____
31-40_____
41-50_____
51+_____
15. Are you currently involved in regular endurance (cardiovascular) exercise?
Yes
No
If yes, please specify the type of exercise(s)_____________________
_____minutes / day
______days / week
16. How often do you eat out?_______________times per week.
17. I would like to:
Lose weight
Gain weight
Feel better
Look better
Live healthier
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Parent category: Medical