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Pre-Exercise Questionnaire
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Member Name
DOB
Parents Name (if under 18)
Address
Email
Phone Work
Phone Home
Mobile
Occupation
What results do you wish to achieve?
Reduce body fat
Strength training
Weight loss
Stress management
Reshaping
Increase fitness
Sports conditioning
Improve muscle tone
Improve flexibility
Rehabilitation
Tone
Other
If other, please specify
Where do you want to achieve your results?
Thighs
Back
Lower back
Stomach
Arms
Hips
Buttocks
Shoulders
Waist
Chest
Calves
Other
If other, please specify (copy)
When would you like to achieve these results?
Why would you like to achieve these results then?
How many days a week do you wish to exercise?
How hong have you been thinking about it?
What has kept you from starting sooner?
On a scale from 1-10 how important is it for you to achieve your results?
Do you smoke?
Yes
No
Are you pregnant?
Yes
No
Have you ever had or experienced…
Heart trouble / history
Arthritis
Epilepsy
Pain in the chest
Asthma
Sports injury
Faint or dizzy spells
Bone or joint problems
Depression
High Blood Pressure
Back Problems
Other
If other, please specify
Acknowledgement
*
I understand that my personal trainer is not able to provide me with medical advice with regard to any medical conditions I may have and that this information is used only as a guideline to the limitations of my ability to exercise. I will not hold my personal trainer liable in any way for any injuries that may occur while I am training.
Guardian Name
Member Name
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Date
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