Client Health & Lifestyle Questionnaire

Every person taking part in my personal training programme must complete the Client Health & Lifestyle Questionnaire below prior to their first session.

Client Information

Name *

Sex *

Date of birth *

Telephone (day) *

E-Mail *

GP Name *

GP Address *

GP Telephone *

Emergency contact and phone number *

Medical Information

Do you have or had any of the following health conditions? If yes please give further details.

Asthma

Heart Disease

Diabetes

Epilepsy

Allergies

Pregnancy

Respiratory Conditions

Bone and Joint Problems

Injuries

Disabilities

Medication

Hypertension

Inherited Risk Factors

Chest Pain

Dizziness

Have you had surgery in the last 6 months?

Have you ever been advised by your GP to refrain from exercise?

Is there any other medication condition that you think I should be aware of?

Lifestyle Information

Please answer the following questions. Where Yes is answered please provide additional details.

Do you smoke?

If yes please indicate approx how many cigarettes you smoke per day

Do you drink Alcohol?

If yes please indicate approx how many units per week

Do you eat a balanced diet?

If no what changes, if any, would you like to make?

At present how often do you exercise?

Please state your current job

Please provide details of your interests and hobbies

What type of exercise or sport do you take part in at present?

What type of exercise do you prefer?

Aims and Objectives

Please detail below the 3 main aims you have for undertaking a program of exercise i.e. relieve stress / weight loss

1.

2.

3.

Availability

Please select your preferred time to exercise

If other please specify

Are you aware of any reason that would prevent you from undertaking a programme of exercise?

If yes please provide details

Any Additional Comments:

I consent to my photo being used for the promotion of Lift Up Fitness on their website and/or social media

0 + 4 = ?Please prove that you are human by solving the equation *

“I was a case study for Karen while she was training. It’s really changed how I see things. I’ve always gone with the all or nothing approach and it’s always been about a short term drive to lose weight fast. Karen has helped me to see it as a lifestyle change and that it needs to be sustainable long term, it’s not about today’s weight but about the whole process, she’s helped me see it as a choice which has taken the guilt out of it all.”

“Karen really knows her stuff so she can explain why we are doing certain exercises which helps with motivation. She’s great at working out what will work for someone and what will make working out more fun for them. I’ve never been an exercise fan but I have genuinely enjoyed our workouts and found that Karen can spot exactly where my limits are and when I could work harder!”

“I really enjoyed the bootcamp class ! It was great to be in teams and I liked the mix of activities, it was well planned and adapted so it could suit us all at our own fitness levels.”

“Enjoyed my HIIT style session with Karen this afternoon. Varied movement with continued encouragement all the way. If you want an all body workout with a laugh mixed in, Karen’s your lady.”

“I really enjoyed yesterdays session. I ache everywhere today which is a sign of a good workout. Your instructions were clear and the exercises were fab, a bit of everything. Thanks.”