PT Client Questionnaire

    Your Details


    Contact Info


    Your Address





    Your Health Goals

    What health goals would you like to achieve over the next 3 months?

    What 3 things could you do in order to improve your health?


    What are your main reasons for starting a fitness programme?

    General Conditioning YesNo
    Muscular Strength YesNo
    Physical Appearance YesNo
    Weight/Fat Loss YesNo
    Aerobic Fitess YesNo
    Improve Self-esteem YesNo
    Stress Management YesNo
    Flexibility YesNo
    Other? Please give further info:

    How would you describe your current general health and fitness?
    Very badBadAverage UntrainedAverage TrainedTrainedGoodAthleteElite Athlete

    Have you done any structured exercises before?
    YesNo

    If yes, what did you do?

    What did you enjoy the most?

    What did you dislike / least enjoy?

    What would you say are the main barriers preventing you from exercising?

    Lack of facilities YesNo
    No motivation YesNo
    No Time YesNo
    Injury/Illness YesNo
    Unfit YesNo
    Appearance YesNo
    Lack of Knowledge YesNo
    Family YesNo
    Work YesNo
    Other? Please give further info:

    Diet and Nutrition

    If doing gym sessions, please state which gym:
    On a scale of 1 -10 (1 = poor, 10 =excellent) assess the quality of your eating habits:

    Would you like help and advice to change the quality of your eating habits?
    YesNo

    If yes, please give any details you wish at this stage:

    Lifestyle

    Do you smoke?
    NoYes If yes, how many cigarettes/cigars/vapes per week

    Do you drink alcohol?
    NoYes If yes, how many glasses per week

    If yes, would you like help and advice to change these habits?
    YesNo

    Medical History

    You should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor.

    Please read each question carefully and answer honestly by indicating YES or NO.

    Have you had a major illness or injury in the last 5 years? YesNo - If yes, please give details:
    Are you receiving treatment for any diagnosed medical condition? YesNo - If yes, please give details:
    Are you taking any prescription medication? YesNo - If yes, please give details:
    Do you ever get unusually short of breath with very light exertion? YesNo
    Do you ever have pain, pressure, heaviness or tightness in the chest area? YesNo
    Do you regularly have unexplained pain in the abdomen, shoulders or arm? YesNo
    Do you know of any other reason why you should not take part in physical activity? YesNo

    Please indicate if you have ever experienced any of the following symptoms/
    Do you:

    Ever have severe dizzy spells or episodes of fainting? YesNo
    Regularly get lower leg pain during walking that is relieved by rest? YesNo
    Are you taking any prescription medication? YesNo - If yes, please give details:
    Ever experience palpitations or irregular heartbeats? YesNo
    Are you currently pregnant or have you given birth in the last 6 months? YesNo
    Do you experience aches, pains and problems in any specific areas:
    e.g. "I always get knee pain when running"    		 YesNo - If yes, please give details:

    Structural Health

    Please give details of any injury areas:

    Are these injuries aggravated by exercise? YesNo
    Are you receiving treatment for any structural problems? YesNo
    Please indicate any other health problems you suffer from which are not already mentioned:

    I confirm that I have answered all questions honestly & the information given is correct.
    I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury

    Sign (Please type name/initials): (required)

    Date Signed: (required)

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