Personal Training Online ConsultationThe following consultation should only take a few moments. Please answer all questions to the best of your knowledge. Begin Consultation Personal Training Consultation First Name Last Name Date of birth (month first) MM DD YYYY Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number Email * What are your goals & objectives? * What would like to notice in particular? (i.e. is there any further elaboration you can make to your goals stated above? Could you give a brief description of your previous/current exercise regime (if any)? Is there a particular reason as to the timing of wanting to start some training sessions? When it comes to exercise, do you have any particular likes / dislikes? If you were to score your strength out of 10 (10 being the best) what would you give yourself? Select 1 2 3 4 5 6 7 8 9 10 If you were to score your fitness out of 10 (10 being the best) what would you give yourself? Select 1 2 3 4 5 6 7 8 9 10 Are you pregnant or have you given birth within the last 12 months? Yes No Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Select Yes No Do you feel pain in your chest when you do physical activity? Select Yes No In the last month, have you had chest pain when you were not doing physical activity? Select Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Select Yes No Have you had an asthma attack requiring medical attention at any time over the last 12 months? Select Yes No If you have diabetes, have you had trouble controlling your blood glucose at any time over the last 6 months? Select Yes No N/A Do you have a bone or joint problem that could be made worse by participating in exercise? Select Yes No Have you had surgery in the past 6 months? Select Yes No Is your doctor currently prescribing drugs for your blood pressure or a heart condition or other serious illness? Select Yes No Do you have any other medical condition or know of any other reason (including the following) that may make it dangerous for you to participate in exercise? Acute Diseases/Inflammation processes Wearing a pacemaker Acute Thrombosis conditions Fresh wounds resulting from an operation or surgical intervention Pregnancy Osteoporosis in an advanced stage Migraine/Epilepsy/Retinal Problems Acute hernia, discopathy, spondylolysis Cardio-vascular disease Wearing recently fitted IUD's, coils, metal pins, bolts or plates Gall and kidney stones Synthetic joints Other If you answered YES to one or more of the above questions, please give details. Terms and Conditions IF YOU ANSWERED YES to one or more questions*: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. IF YOU ANSWERED NO to all questions: You can be reasonably sure that it is safe for you to participate in physical activity, gradually building up from your current ability level. ------- “I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury”. *Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise. Please enter todays date (month first) MM DD YYYY Thank you! GDPR NoticeAll personal data is collected, transmitted and stored in accordance with my privacy policy. It is not shared with any other individual or company.
