Ymca Personal Training Questionnaire Page 4
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15Yes
No
Do you smoke cigarettes?
If yes, how often?
Yes
No
Are you a past smoker?
If yes, when did you quit?
Yes
No
Do you drink alcoholic beverages?
If yes, how much, often?
Yes
No
Are you presently dieting or on a weight control program?
If yes, please provide a brief explanation.
Do you have any past or present medical conditions, not already addressed, which may influence your ability to
safely participate in an exercise program? If yes, please explain.
Please provide a brief explanation of your current exercise program. Include types of activity and frequency.
What are your current health and fitness goals? Please be as specific as possible.
Do you foresee any barriers that may prevent you from adhering to a regular exercise program?
How do you rate your level of motivation and commitment to achieving your goals? (circle one)
Low
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High
Yes
No
Have you worked with a personal trainer in the past?
When are you available to meet with a trainer?
Morning
Day
Evening
Other:
Male
Female
No preference
Do you prefer to work with a male or female trainer?
How did you hear about YMCA Personal Training?
Brochure/Flyer
Referral from friend
YMCA staff
Promotional offer
YMCA Website
Other:
Page 3
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