PHYSICAL ACTIVITY REQUIREMENT QUESTIONNAIRE

PERSONAL DETAILS:
Full Name: _____________________________

Sex: (Please Tick)

Address: _______________________________

D.O.B:

________________ Suburb: _______________

Contact Phone Number: ______________

Postcode: ____________ State: _____________

Mobile: ____________________________

Emergency Contact Name: _________________

Emergency Contact Number: ___________

______/______/______________

Occupation: _____________________

MEDICAL HISTORY:
Please circle Yes or No for the following questions:
Do you smoke?
Do you suffer from epilepsy?
Do you have diabetes?
Have you ever had a stroke?
Have you ever had frequent dizzy spells or feeling of nausea?
Do you drink alcohol?
Are you, or could you possibly be pregnant?
Do you suffer from asthma?
Have you had recent surgery?
Has a medical professional ever diagnosed you with osteoporosis?
Has a medical professional ever told you that you have high blood pressure?

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No

If you answered Yes to any of the above questions, please give details below.
__________________________________________________________________________________
__________________________________________________________________________________
Are you being treated for any other medical condition?

Yes

No

If yes, please give details. _____________________________________________________________

__________________________________________________________________________________

Jo-Ann Goss

Has your doctor, or any health care professional ever advised you against any form of exercise?
__________________________________________________________________________________
__________________________________________________________________________________

Are you currently taking any medications? (If yes, please list below)

Yes

No

__________________________________________________________________________________
Is there any known reason/s that prevents you from participating in any physical activity? (If yes, please
explain below)
Yes
No
______________________________________________________________________________________

Do you suffer from any back pain? (If so, please explain below)

Yes

No

______________________________________________________________________________________

Do you suffer from any bone/joint/muscle problems? (If so, please explain below:
______________________________________________________________________________________

Are you aware of any injury, past or present, which may be aggravated by any form of exercise? Yes

No

If YES, please explain: ________________________________________________________________________

__________________________________________________________________________________________

Jo-Ann Goss

EXERCISE HISTORY
Please tick one of the following boxes to indicate the amount of physical activity you perform on a daily basis:
Very Low
Low
Moderate
Active
Very Active

Which types of training have you had previous experience with?

TYPE

EXAMPLES

Cardiovascular training

Walking, Jogging, Running

Endurance training

Long distance running

Strength training

Free weights, resistance machines

Flexibility training

Yoga, Pilates

Hypertrophy training

Bodybuilding

YES

NO

Regular gym sessions

Other (Please specify)

Please specify any current or past sport/s you have played:

Current: ___________________________________________________________________________________
Past: ______________________________________________________________________________________
How long have you been training for? ___________________________________________________________
How many days per week do you train? _________________________________________________________
How long do you train for? ___________________________________________________________________

Jo-Ann Goss

PERSONAL GOALS:
(Please tick and explain)
Improve strength: __________________________________________________________________
Gain muscle: _______________________________________________________________________
Lose Weight: _______________________________________________________________________
Improve Muscle Tone/Shape: _________________________________________________________
Improve diet/eating habits: ___________________________________________________________
Improve flexibility: __________________________________________________________________
Reduce stress/increase energy: ________________________________________________________
Injury prevention/rehabilitation: _______________________________________________________
Any additional goals: ________________________________________________________________

The information contained in this form will be used as part of establishing a training
program. Details will not be disclosed for any other purpose.

Disclaimer:
I (name) ___________________ hereby declare that the above information is correct and true to as
best of my current knowledge on (date)______________. I understand that if any information was
given misleadingly or false, that I may be liable for any damages or injuries incurred while being
trained. I acknowledge that any exercise I undertake involves a degree of risk.
Signed: _________________

Date: ____________

Thankyou for taking the time to answer all the above questions, now that this stage is over, lets get
you closer to starting your exercise program and begin changing your life!

Jo-Ann Goss