Health/medical Questionnaire Form (Page 2 of 2) in pdf

Explain checked items: _________________________________________________________________________

______________________________________________________________________________________________

Activity History

1. How were you referred to this program? (Please be specific.) ___________________________________

________________________________________________________________________________________

2. Why are you enrolling in this program? (Please be specific.) _____________________________________

________________________________________________________________________________________

3. Are you presently employed? Yes ___ No ___

4. What is your present occupational position? _________________________________________________

5. Name of company: _______________________________________________________________________

6. Have you ever worked with a personal trainer before? Yes ___ No ___

7. Date of your last physical examination performed by a physician:

8. Do you participate in a regular exercise program at this time? Yes ___ No ___ If yes, briefly describe:

________________________________________________________________________________________

9. Can you currently walk 4 miles briskly without fatigue? Yes ___ No ___

10. Have you ever performed resistance training exercises in the past? Yes ___ No ___

11. Do you have injuries (bone or muscle disabilities) that may interfere with exercising? Yes ___ No ___ If

yes, briefly describe: _____________________________________________________________________

________________________________________________________________________________________

12. Do you smoke? Yes ___ No ___ If yes, how much per day and what was your age when you started?

Amount per day ______ Age ______

13. What is your body weight now? ____ What was it one year ago? ____ At age 21? ____

14. Do you follow or have you recently followed any specific dietary intake plan, and in general how do you

feel about your nutritional habits? __________________________________________________________

________________________________________________________________________________________

15. List the medications you are presently taking. ________________________________________________

________________________________________________________________________________________

16. List in order your personal health and fitness objectives.

a. _____________________________________________________________________________________

_____________________________________________________________________________________

b. _____________________________________________________________________________________

_____________________________________________________________________________________

c. _____________________________________________________________________________________

_____________________________________________________________________________________

From NSCA, 2012, NSCA’s essentials of personal training, 2nd ed., J. Coburn and M. Malek (eds.), (Champaign, IL: Human Kinetics).

Health/medical Questionnaire Form Page 2