Personal Fitness Questionnaire

ASSESING YOUR NEEDS:

Please fill out this questionnaire honestly and accurately. This information is essential in the
development of a program that will address your specific needs, goals and interest safe and effectively.

Name: Date of Birth:

Address:

Street City State Zip Code

Phone: (H)
(C)
(O)

Email Address:

Occupation:

What is your reason for investing in Personal Training? (Mark X)

1. Loose Body Fat 2. Develop Muscle Tone

3. Rehabilitate an Injury 4. Start an Exercise Program
5. Sport Specific Training 6. Increase Muscle Size
7. Fun 8. Other:

Fitness History
1. When were you in the best shape of your life?

2. Have you been exercising consistently for the past 3 months?

Yes No

3. When did you first start thinking about getting in shape?

4. What has prevented your from reaching your fitness goals in the past?

5. On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?

Exercise Related Questions:

Skip to next section if you are presently inactive.

1. How often do you take part in physical exercise (i.e. 1-3x/week)

2. If your participation is lower than you would like it to be, what are the reasons?

3. How long have you been consistently physically active for?

4. What activities do you currently engaged in?

Goal Setting
1. Please list in order of priority 3 fitness-based goals you would like to achieve over the next
3-6 months?
a)

b)

c)

2. How will you feel once you've achieved these goals? Be specific.

3. What priority does health have in your life? (Low|Medium|High Priority)

4. How committed are you to achieving your fitness goals?

5. Outline any obstacles, potential actions, behaviors or activities that could limit your
progress towards accomplishing your goals (i.e. not training consistently, upcoming
vacation, busy season at work, not following the program, allowing other responsibilities to
become a priority over exercise etc.).

Nutrition & Lifestyle

YOU ARE WHAT YOU EAT

1. Do you shop less frequently than every four days?

Yes No

2. Do you eat more packaged (frozen or canned) fruits and vegetables than fresh?
Yes No

3. Do you eat vegetables with less than two meals daily?

Yes No
4. Do you use a microwave oven?
Yes (check option below) No
1-2 times per week
3-4 times per week
more than 4 times per week

5. Do you eat quick cook grains such as Rice-aroni, Quaker Oats or Minute rice more often
than slow cooked organic whole grains?
Yes No

6. Do you eat white bread more often than whole grain breads?
Yes No

7. Do you drink pasteurized/homogenized milk, or eat cheeses frequently?

Yes No
8. Do you eat red meat more than once every four days?
Yes No

9. Do you eat canned fish more frequently than fresh fish?

Yes No

10. Do you eat nuts and/or seeds that are roasted and/or salted?
Yes No

11. Do you use standard white table salt?

Yes No

12. Do you eat TV dinners or other highly processed foods more than three times a week?
Yes No

13. Do you eat from fast food restaurants like McDonald's, Arby's, Wendy's, etc.?
Yes (check option below) No
1-2 times per week
3 times per week
more than 3 times per week

14. Do you eat from vending machines?

Yes (check option below) No
1-2 times per week
3 times per week
more than 3 times per week

15. Do you eat some form of store bought dessert, such as ice cream, cookies, donuts, cakes
or pies after dinner most nights?
Yes (check option below) No
once a week
2-3 times per week
more than 3 times per week

YOU ARE WHEN YOU EAT

1. Do you frequently skip meals?

Yes No

2. Do you typically go more than four hours without eating?

Yes (check option below) No
1-2 times per week
3 times per week
more than 3 times per week

3. Do you sometimes skip breakfast?

Yes (check option below) No
2 times per week
3 times per week
more than 3 times per week

4. Do you avoid fats when eating?

Yes No

5. Do you frequently snack (i.e. breads, bagels, cookies, pasta, fruit, cereals,
muffins, crackers, chocolate, or candy)?
Yes No

6. Do you get hungry or crave sweets within two hours after eating a meal?
Yes No

7. Do you use caffeine and/or sugar containing drinks to stay alert during the day?
Yes (check option below) No
1 cup a day
2 cups per day
more than 2 cups per day

8. Have you tried diets to lose weight?

Yes No

9. Do you have difficulty burning fat around your belly, hips or thighs even with regular
exercise?
Yes No

10. Do you eat your largest meal at night?

Yes No

Regular physical activity is fun and healthy, and increasingly more people are starting to
become more active every day. Being more active is very safe for most people. However, some people
should check with their doctor before they start becoming more physically active.
If you are planning to become much more physically active than you are now, start by
answering the seven questions below. If you are over 65 years of age, and you are not used to being
very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions
carefully and answer each one honestly:

1. Has your doctor ever said that you have a heart condition and that you should only do physical
activity recommended by a doctor?
Yes No

2. Do you feel pain in your chest when you do physical activity?

Yes No

3. In the past month, have you had chest pain when you were not doing physical activity?
Yes No

4. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes No

5. Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a
change in your physical activity?
Yes No

6. Is your doctor currently prescribing drugs for blood pressure or heart condition?
Yes No

7. Do you know any other reason why you should not do physical activity?
Yes No
(If yes why)

If you have answered YES to one or more questions:

Talk to your doctor by phone or in person before you start becoming much more physically active or
before you have a fitness appraisal.

You may be able to do any activity you want – as long as you start slowly and build up gradually. Or
you may need to restrict your activities to those that are safe for you. Talk with your doctor about the
kinds of activities you wish to participate in and follow his or her advice.

Find out which community programs are safe and help for you.
If you have answered NO honestly to all question, you can be reasonably sure you can:
Start becoming much more physically active – begin slowly and build up gradually.

Take part in a fitness appraisal – this is an excellent way to determine your basic fitness level so that
you can plan the best way for you to live actively.

I have read, understood and completed this questionnaire. Any questions I had were answered to
my full satisfaction.

Name

Signature Date