Personal Training - Lifestyle & Health History Questionnaire

Name*

First Last

Date of Submission*

Birthdate*

Medical Information

How would you describe your present state of health?

Very well
Healthy
Unhealthy
Unwell
Other

List current medications, how often you take them, and dosages

Include prescriptions and over-the-counter medications

Do you take all of your medications as they have been prescribed by your healthcare provider?

Yes
No

If not, please share why.

e.g., cost, side effects, or feeling as though they are unnecessary

Do you take any vitamin, mineral, or herbal supplements?

Yes
No

If yes, list type and amount per day.

Check any that apply to you and list any important information about your condition:

Allergies

specify

Major Surgeries

specify

Past Injuries

specify

Other Health Conditions

specify

Nutrition

Have you ever followed a modified diet?

Yes
No

If yes, describe

Are you currently following a specialized eating plan?

e.g., low-sodium or low-fat

Yes
No

If yes, what type of eating plan?

Why did you choose this eating plan?

Was the eating plan prescribed by a physician?

Yes
No

How long have you been on the eating plan?

Have you ever met with a registered dietitian?

Yes
No

If no, are you interested in doing so?

Yes
No

How many glasses of water do you drink per day?

8-ounce glasses

What do you drink other than water?

List what and how much per day.

Do you have any food allergies or intolerance?

Yes
No

If yes, what?

How often do you dine out?

times per week

Substance-related Habits

Do you drink alcohol?

Yes
No

If yes, how often?

times per week

Average amount?

Do you drink caffeinated beverages?

Yes
No

If yes, average number per day

Do you use tobacco?

Yes
No

If yes, how much

cigarettes, cigars, or chewing tobacco per day

Physical Activity

How many minutes of cardiorespiratory activity per week?

How many minutes of muscular-training sessions per week?

How many minutes of flexibility-training sessions per week?

How many minutes of sports or structured recreational activities per week?

List sports or activities you participate in:

Have you ever experienced any injuries that may limit your physical activity?

Yes
No

If yes, describe

Do you have any physical-activity restrictions?

Yes
No

If so, please list

What are your honest feelings about exercise/physical activity?

What are some of your favorite physical activities?

Occupational

What is your occupation?

What is your working routine?

Stay at home parent
Commute to office
Work from home
Hybrid working routine
Retired

What is your work schedule?

Describe your activity level during the work day

Sleep & Stress

How many hours of sleep do you get at night?

Rate your average stress level

from 1 (no stress) to 10 (constant stress)

What is most stressful to you?

How is your appetite affected by stress?

Increased
Not Affected
Decreased

Goals

On a scale of 1 to 10, how likely are you to adopt a healthier lifestyle

1 = very unlikely; 10 = very likely

Do you have any specific goals for improving your health?

Yes
No

If yes, please list them in order of importance.

Do you have a weight-loss goal?

Yes
No

If yes, what is it?

Why do you want to lose weight?

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Personal Training – Lifestyle & Health History Questionnaire

Medical Information

Nutrition

Substance-related Habits

Physical Activity

Occupational

Sleep & Stress

Goals

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