HEALTH, LIFESTYLE & PHYSICAL ACTIVITY READINESS QUESTIONAIRE

Questionnaire

First Name

Last Name

DOB

Contact Number

If you suffer from a physical or psychological medical condition or illness which can impact your fitness training in the gym or outside the gym, please detail below

If you had surgery on any part of your body, if so, does it give you pain or discomfort please detail below

What is your exercise likes and dislikes?

What do you want to learn more about when you train?

What is your medium-term fitness goal? (3-6 months)

What would it mean to you to achieve this goal? How would you feel?

How important would you rate this goal on a scale of 1-10? (1 not important & 10 extremely important)

Why do you feel you have not achieved your goals yet?

If you did not achieve this goal how would you feel?

How much alcohol do you drink each week?

Do you smoke or take drugs?

Yes

If you have a stressful job or experience stress each week, please detail below.

In signing this form, you agree that Personal Training at Home provides fitness training in the form of home based personal training and fitness programmes and packages. We aim to help get you results, but you have the responsibility to follow our nutritional advise, train consistently outside of our sessions and eat a clean and balanced diet. I understand that I cannot hold Personal Training at Home responsible for not achieving results as a part of it is my responsibility.

Date / Time

Signature

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