PRE-EXERCISE

QUESTIONNAIRE

PERSONAL DETAILS

NAME DATE OF BIRTH GENDER

M/F

POSTAL ADDRESS STREET ADDRESS (IF HEIGHT CM

DIFFERENT TO POSTAL WEIGHT KG
ADDRESS)

PHONE (H) (W) (M)

EMAIL OCCUPATION

EMERGENCY CONTACT RELATIONSHIP TO YOU

CHILDREN NAMES AGES

PHONE (H) (W) (M)

MEDICAL DETAILS
NAME & LOCATION OF CLINIC ________________________________________________

NAME OF GENERAL PRACTITIONER ________________________________________________

TELEPHONE NUMBER ________________________________________________

If you have any pre-existing or medical conditions, I recommend that you discuss your exercise intentions with your
doctor.

Have you discussed your exercise intentions with the General Practitioner? YES OR NO

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MEDICAL PROFILE
YES//NO Have you ever had a heart attack, coronary surgery or a stroke?
YES//NO Has your doctor told you that you have heart trouble, vascular disease or heart murmur?
YES//NO Do you suffer from pains in your chest, especially during exercise?
YES//NO Do you ever get pain in your calves, buttocks or at the back of your legs during exercise
which are not due to soreness or stiffness?
YES//NO Do you ever feel faints or have severe dizziness, particularly during exercise?
YES//NO Do you suffer from swelling in your ankles?
YES//NO Do you ever get the feeling that your heart is suddenly beating faster, racing or skipping
beats, either at rest or during exercise?
YES//NO Do you have chronic obstructive pulmonary disease, interstitial lung disease or cystic
fibrosis?
YES//NO Have you had an attack of shortness of breath that developed when you were not doing
anything strenuous, at any time in the last 12 months?
YES//NO Have you been woken at night by an attack of shortness of breath at any time in the last 12
months?
YES//NO Do you have diabetes and if so what type? Type 1 or Type 2 (please circle)
YES//NO If yes, is your diabetes under control?
YES//NO Do you have any ulcerated wounds or cuts on your feet that do not seem to heal?
YES//NO Do you have any liver, kidney or thyroid disorders?
YES//NO Are you, or do you have reason to believe, that you may be pregnant?
YES//NO Is there any other physical or medical reason, or are you taking any medication which could
prevent you from undertaking an exercise program ie: cancer, osteoporosis arthritis, epilepsy,
asthma, mental illness, gastric banding?
IF YES PLEASE PROVIDE DETAILS:

YES//NO Do you smoke on a daily basis; if so how many would you smoke per day?
YES//NO Did you quit smoking in the last 2 years?
YES//NO Do you have a close relative who has had a stroke, heart attack or suffered from
cardiovascular disease?
IF YES WHAT RELATION WAS THIS PERSON TO YOU?
AT WHAT AGE WERE THEY WHEN DIAGNOSED?
DID YOUR RELATIVE DIE SUDDENLY AS A REULTS OF STROKE OR HEART ATTACK?
YES//NO Have you experienced menopause before the age of 45?
IF YES DO YOU TAKE HORMONE REPLACEMENT MEDICATION?
YES//NO Has your doctor ever told you that you have high blood pressure?
YES//NO Have you recently had your blood pressure checked?
IF YES WHAT WAS YOUR BLOOD PRESURE?
YES//NO Have you recently had a cholesterol test?
IF YES,
WHAT WAS YOUR SERUM CHOLESTEROL LEVEL?
WHAT WAS YOUR SERUM HDL LEVEL?
WHAT WAS YOUR SERUM TRIGLYCERIDE LEVEL?
YES//NO Have you been seriously ill in the last 12 months?
IF YES PLEASE PROVIDE DETAILS:

YES//NO Have you had any major surgery?

IF YES PLEASE PROVIDE DETAILS

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 Describe any injuries you have in the past:

Please circle any of the following areas where you have a physical injury or weakness:

Lower/Upper/Middle Back Hip Knee Ankle Neck

Shoulder Elbow Wrist Other __________________

Are there any other medical/exercise issues that you wish to share with me even if it is not directly related
to your participation in exercise (eg: allergies)
_____________________________________________________________________________________
_____________________________________________________________________________________

CURRENT FITNESS/ACTIVITY PROFILE

1. How would you describe your activity levels during the day?
ie: do you sit at a computer-do you stock shelves
INACTIVE LIGHTLY ACTIVE VERY ACTIVE
2. Do you have any previous background in sport/physical activity? YES NO
If yes, what sport/activity? _____________________________________
3. Do you currently exercise? YES NO
SESSIONS ______________PER WEEK
MINUTES ______________PER SESSION
4. What type of exercise do you do
___________________________________________________________________________
___________________________________________________________________________
5. What type of exercise do you enjoy or would you enjoy
WALKING RUNNING CYCLING WEIGHTS CIRCUITS BOXING
RESISTANCE BANDS NORDIC WALKING PILATES
OTHER_____________________
6. Do you have any fitness equipment at home ie: treadmill, weights, bands, fitball ect please list
below
_______________________________________________________________________________
_________
_______________________________________________________________________________
_______________________________________________________________________________
__________________

GOAL SETTING
1. What is your motivation for choosing to exercise with a personal trainer
_______________________________________________________________________________
_______________________________________________________________________________
2. Please circle the following, that you wish to improve through fitness:

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 STRENGTH FLEXIBILITY INCR CARDIOVASCULAR FITNESS OVERALL HEALTH

SOCIAL/FUN STRESS RELIEF LOVING YOURSELF MORE REDUCE PAIN

REHABILIATION WEIGHT LOSS INCREASE ENERGY LEVELS OTHER _____________

3. How many times a week do you want to exercise ________________________

4. What day & time suits you best __________________________________________________

5. What are your:

Short term goals _________________________________ Date to achieve
Medium term goals _________________________________ Date to achieve
Long term goals __________________________________ Date to achieve

6. In order for me to support you I will need to keep in contact with you during the week, how may I
best do this to keep you motivated and on track?
PHONE EMAIL TEXT

PLEASE READ THE FOLLOWING DECLARATION STATEMENT & IDEMITY

STATEMENT

I ________________________________________ACKNOWLEDGE THE FOLLOWING:

(INSERT YOUR FULL NAME)

1. ROADMAP TO FITNESS HAS ADVISED ME TO VISIT MY GP PRIOR TO COMMENCING

ANY EXERCISE PROGRAM SHOULD I FEEL IT IS GOING TO COMPROMISE MY HEALTH
2. I PROMISE TO ADVISE ROADMAP TO FITNESS, SHOULD ANY OF THE PROVIDED
INFORMATION CHANGE OR SHOULD I DEVELOP NEW HEALTH/LIFESTYLE ISSUES.

INDEMNITY STATEMENT

I recognise that RoadMap to Fitness is not able to provide me with medical advice in
regards to medical fitness and that this information is used as a guideline to the
limitations of my ability to exercise. I have to the best of my knowledge provided
accurate information regarding my current health status. I agree that my trainer shall
not be liable for any loss, damage or injury to myself or my property suffered as a
result of exercise or other activity, whether directly or indirectly arising out of any act
or omission by my trainer. I acknowledge sole responsibility for any personal
equipment. I consent to receive medical treatment, which may be deemed necessary
in the event of injury, accident or illness.

FULL NAME ____________________________________________________________

SIGNATURE _______________________________ DATE _________________

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