| Personal History Questionnaire |
| The following questions are designed to help Personal Trainers Network evaluate your personal fitness needs, however, we also recognize and respect your need for privacy. Please feel free to omit any information that you may feel uncomfortable about sharing. |
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| *First Name |
*Last Name |
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| *Address |
*City |
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| *State/Province/County |
*Country |
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| *Postal Code |
*Email |
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| *Telephone |
Work Phone |
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| Mobile/Cell |
Age |
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| Height |
Weight |
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| Activity Level |
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| Goals/Aims |
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| Medical Questions |
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| Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? |
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| Do you feel pain in your chest when you do physical activity? |
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| In the past month, have you had chest pain when you were doing physical activity? |
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| Do you lose your balance because of dizziness or do you ever lose consciousness? |
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| Do you have a bone or joint problem that could be made worse by a change in your
physical activity? |
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| Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? |
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| Do you know of any other reason why you should not do physical activity? |
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| About Your Trainer |
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| Would you prefer a male or female trainer? |
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| Please give a short description of what you require in a trainer |
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| Lifestyle Questions |
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| Occupation |
How do you spend the majority of |
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your time at work?
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If yes, how many per day? |
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| How would you rate your current |
How much water do you consume daily? |
| Eating habits?
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| How would you like to change your current eating habits? |
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| Training Details |
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| How long have you been training? |
How often do you train? |
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| How long is each training session? |
What time of day do you usually train? |
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| What sports do you particpate in? |
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| Training Goals |
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| Please select one of the training programmes that best describes your goals |
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| Are their any body parts in particular that you wish to train? |
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| Please describe your current knowledge of exercise and weight training |
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| If you have a good knowledge of exercise and weight training, please best describe your current training routine |
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| Terms and Conditions |
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Personal Trainers Network shall have no liability for any injury, illness or similar difficulty that arises out of or connected with any instructions or guidance provided by any personal trainer provided by us.
Personal Trainers Network assumes you have had medical clearance and doctors consent to participate in an exercise program. You must agree that you assume the risks associated with any and all activities and/or exercises in which you participate. |
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| I accept the above terms and conditions |
| Enter the following string as it appears(case-sensitive) into the space below : |
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