PT Questionnaire Let me help with your fitness journey. It all starts by filling out the PT form and I’ll be in touch for an initial consultation. Personal Details Name * First Name Last Name Email * Mobile Date of Birth MM DD YYYY Gender M F Occupation Emergency contact (ICE) ICE Phone (###) ### #### Personal and/or Family Illnesses Have you or your direct family had any of the following? (select all that apply) Diabetes Heart Problems High / Low Blood Pressure Stroke Asthma Chest pain Arthritis Epilepsy Osteoporosis High Cholesterol Smoking Do you or have you ever smoked? Yes No If yes, # of smokes per day If you stopped smoking, how long ago did you stop? Physical Activity Profile Activity level (select one) Inactive Active If active, how frequently? E.g. per week How intensely? (select one) Light Moderate Vigorous APMHR Is there anything else that may affect you exercising? Medications and Blood Pressure Do you take any pills, tablets, medicine or medication? Yes No If yes, please describe Blood Pressure (BP) if known Injury Profile Have you ever injured any of the following areas of your body? (select all that apply) Head/Neck Back/Torso Shoulders Arms Hands / Wrists Hips Upper Legs Knees Lower Legs Ankles / Feet Goal Setting I want to see… More tone/shape More muscle Less body fat I want to feel… More energetic Healthier Less stressed & more relaxed I want to be… Fitter Stronger Happier Barriers, Support and Intervention What factors have helped you previously achieve your goals? E.g. people, scheduling, support networks. What factors do you think could get in the way of achieving your goals? How likely is it that these factors will affect your progress? What support are you expecting from your trainer? Which phrase best describes your motivation levels? I am self-motivated I find exercise easier to stick to if I have a partner I find exercise easier with regular appointments I usually experience some problems staying motivated I need constant motivation Lifestyle On a scale of 1 to 10, how is your sleep quality? 10 being high quality sleep, 8+ hours of uninterrupted sleep. On a scale of 1 to 10, how is your energy/fatigue levels? 10 being consistent energy throughout the day, no crashing. On a scale of 1 to 10, how is your stress levels? 1 = happy and content, never anxious, look forward to your day. 10 being extremely stressed. On a scale of 1 to 10, how is your nutrition? 10 being plenty fruit and vege and water, minimal processed foods, you feel great after each meal. Exercise History If you are currently exercising. What activities are you doing? What do you like or dislike about them? E.g. environment, intensity, equipment. If you have previously exercised. What activities did you do? What did you like or dislike about them? E.g. environment, intensity, equipment. Exercise Preferences How often would you ideally like to train? On a scale of 1 to 10, how intense would you like to exercise? On average, 10 being extremely hard/intense On average, how long would you like to exercise for? What is your preferred workout style and or would like to try? Weights Cardio High intensity interval training Yoga Circuit training Thank you! Get started and book a 30 minute phone consult. Book Now
