Medical History

Please mark YES or NO to the following questions:

1) Has your doctor ever said that you have a Heart condition and that you should only do physical activity when recommended by the doctor? _____ / _____

2) Have you ever had a Heart Attack or Coronary Heart Disease? _____ / _____

3) Do you feel pain in your chest when you perform physical activity? _____ / _____

4) In the past month, have you had a chest pain when you were not doing physical activity? _____ / _____

5) Do you lose balance because of dizziness or do you ever lose consciousness? _____ / _____

6) Do you have any Injuries or Bone, Joint or any other problems that could be made worse when performing physical activity or causes you pain or limitations that must be addressed when developing an exercise program i.e. Back, Knee, Shoulder, Wrist, Spine, problems, etc.. ? _____ / _____

( If you have answered YES to this question please give details ): ________________________________________________________________________________________________________________________________________________________________

7) Have you had any Surgeries? _____ / _____

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8) Do you have any Chronic illnesses or physical limitations that could be made worse when performing physical activity or causes you limitations that must be addressed when developing an exercise program i.e. Diabetes, Osteoporoses, High Blood pressure, High Cholesterol, Arthritis, Anorexia, Bulimia, Anemia, Epilepsy, Asthma or other respiratory problems? _____ / _____

( If you have answered YES to this question please give details ): ______________________________________________________________________________________________________________________________________________________________________________________________

9) Do you take any medication either prescription or non-prescription on a regular bases? _____ / _____

( If YES what is the medication for? ________________________________________________________________________________________________

How does it effect your ability to perform physical activity? ________________________________________________________________________________________________________________________________________________________________

10) Are you Pregnant now or have you given birth within last 6 month? _____ / _____

11) Is there any other reason why you should not engage in physical activity? _____ / _____

If YES please give more details:

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• Physical Exercise History

1) What are your goals ? What are you trying to achieve?

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2) Why have you set yourself these goals? What will it mean to you to achieve these ?

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3) On a scale between 1-10 ( 1 - being lowest) Where are you NOW? __________

4) How Motivated do you feel to START? ______________

Physical Exercise History continue

5) What do you expect from me as a trainer? ______________________________________________________________________________________________________________________________________________________________________________________________

6) Have you ever tried to achieved these goals before? _________ When?________________________________________________________________________________________________________________________________

Did it work? ________ If YES how did you achieve it? ________________________________________________________________________________________________________________________________________________________________

7) What is your PREVIOUS Exercise, Physical activity experience?

(How often, what level/intensity?)

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8) Are you physically active/ do exercise at PRESENT? _________ If YES

What do you do? And How often? ________________________________________________________________________________________________________________________________________________________________

If NO how long it has been since you did any regular exercise? ________________________________________________________________________________________________

• Lifestyle

1) What are your Hobbies/ Pastimes? ______________________________________________________________________________________________________________________________________________________________________________________________

2) What are your Exercise LIKES / DISLIKES? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________3) Describe your Job: ________________________________________________________________________________________________________________________________

4) How many hours do you regularly sleep at night? __________________________

5) On a scale 1-10 how would you rate your Stress level (1-lowest)? ________________

List your 3 biggest sources of stress?

a) ________________________________________________________________

b) ________________________________________________________________

c) ________________________________________________________________

6) Do you allocate time for Relaxation? ______ If YES what do you like to do? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7) Do you Smoke? ____ If YES how many? _____________________________

8) Do you drink alcohol? ______ If YES how many units/glasses/week? ______________________________

9) How many cops of coffee, black tea, juices, carbonated drinks per day? ________________________________________________________________________________________________________________________________________________________________

10) How many meals per day do you eat? _____

11) How often do you eat out/ takeaways? __________________

12) Is there anything you would like to change about your Lifestyle other then exercise?

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