CLIENT QUESTIONNAIRE | Clarke Health & Fitness

First name

Last name

Address

Phone

Email

Gender

Male

Female

Date of Birth

Day

Month

Year

Current Weight

Current Height

Resting Heart Rate

WORK INFORMATION

Job Title

Do you follow a regular work schedule? (shift work etc)

What is your activity level at work?

None (seated)

Moderate (light activity such as walking)

High (heavy labour, very active)

Do you travel for work?

Rarely

Monthly

Weekly

HEALTH INFORMATION

If you have any diagnosed health problems, please list the condition(s).

If you are on any medications, please list the medication(s).

HEALTH QUESTIONS (please tick the box if yes)

Are you suffering from a heart condition (heart attack, angina, irregular beat, hole in heart etc.)?

Do you feel pain in the chest when performing physical activity?

Do you suffer from high or low blood pressure?

Are you taking medication to control your blood pressure or a heart condition?

Do you have a back or joint problem that could be made worse through physical activity?

Do you have diabetes?

Do you suffer from respiratory Illness (asthma, bronchitis, emphysema) or have shortness of

breath with mild exertion?

Are you under medical treatment for any illness?

breath with mild exertion?

Are you currently a smoker? (including vape)

GOALS

Which day works best for long sessions?

Briefly explain your current health and fitness regime?

How many hours can you train each week and your preferred rest day?

What are your short, medium and long term training goals?

Why are you interested in hiring a coach?

Have you ever been tested? (for example your max HR)

Any further comments

DECLARATION

I understand that I should inform Clarke Health and Fitness of any medical conditions that may not have been covered in this form and that I am advised to visit my doctor prior to commencing training.

I acknowledge that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in the activity and/or use the equipment and machinery

without the approval of my doctor and do hereby assume all responsibility for my participation and activities. I release Clarke Health and Fitness, the PT and any other PT’s who train me from any liability for personal injury or other damage I may sustain whilst engaging in any exercise programme suggested by the Personal Trainer.

I acknowledge receipt of this agreement and confirm acceptance of the terms and conditions herein.

Signature

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