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
Height
Weight
Best Day(s) for Training
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

Rows	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