Starport Personal Training Consultation Questionaire

Starport Personal Training Client Questionnaire
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Direct Employer*
Birth Date*

MonthDayYear
Age*
Gender*

MaleFemale
Height*
Weight*
Best Day(s) for Training*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Best Time(s) for Training*
Please read each question carefully. The questions are designed to identify those who should consult a physician prior to beginning a program of physical exercise.

Health History*

	Yes	No
1. Has a doctor ever said you have a heart condition and recommended medically supervised physical activity?
2. Do you have chest pain brought on by physical activity?
3. Do you tend to lose consciousness, feel faint or have spells of dizziness?
4. Has your doctor recommended medication for blood pressure?
5. Do you have a bone or joint problem (such as arthritis) that could be aggravated by physical activity?
6. Are you aware of any other physical reason against your exercising without medical supervision?
7. Are you over the age of 65 and not accustomed to vigorous exercise?

Starport Personal Training Client Questionnaire