www.beyondbelief-fitness.co.uk 07507 413229

Lifestyle questionnaire

Assessing your needs: all the information received on this form will be kept strictly confidential. Please fill out the forms completely and accurately as this is essential in helping your Personal Trainer develop a programme that addresses your needs, goals, and interests and is safe and effective.
Name: / DOB / Age: / Ht: / Wt:
Address:
Phone: / (home) / (work) / (mobile)
Email Address: / Occupation:
GP’s name: / Phone
GP’s address:
Please indicate why you have decided to invest in personal training
lose body fat / safety
develop muscle tone / sports specific training
rehabilitate an injury / increase muscle size
nutrition education / fun
start an exercise programme / motivation
design a more advanced programme / increase flexibility
other (please state below)
Physical activity (place an X in the appropriate box)
1.  Do you currently take part in any structured activity?
(Swimming, running, cycling, aerobics, resistance, etc)
3-4 times per week
1-2 times per week
1-2 times per month
not at all
2.  Do you currently take part in any unstructured activity?
(Gardening, walking, stair climbing, housework, active job etc)
3-4 times per week
1-2 times per week
1-2 times per month
not at all
3. Are you completely inactive?
Yes / No
4. What types of physical activity do you enjoy?
5. What don’t you enjoy and why not? (barrier to exercise)
6. Do you have any negative feelings toward, or have you had any bad experience with exercise? (If yes please give details)
7. If you have been unable to exercise regularly, what are the reasons?
8. Does your occupation involve much physical activity (i.e. lifting, walking)?
9. How many days per week are you willing to exercise and for how long?
Health and well being (place an X in the appropriate box)
10. Do you work shifts or unusual hours?
Yes / No
11. How many hours sleep do you have on an average night?
12. How many units of alcohol do you consume in an average week?
13. Are these consumed throughout the week or on one occasion?
Weight (place an X in the appropriate box)
14. Do you consider your weight to be a problem?
Yes / No
15. Would like to lose weight?
Yes / No / How much?
16. Is the rate at which you lose weight important to you?
Yes / No
17. If yes, what is the timescale that you would like to lose it?
Motivation (Place an X in the appropriate box)
(select the number that best applies – 10 = high or similar indicator and 1 = low )
18. How motivated are you to perform exercise (individually)?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
19. How motivated are you to perform exercise (with a partner or group)?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
20. How motivated are you to achieve your goals (individually)?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
21. How motivated are you to achieve your goals (with a partner or group)?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Rate how important the following is to you (Place an X in the appropriate box)
(select the number that best applies – 10 = high or similar indicator and 1 = low )
22. Improve overall health
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
23. Improve cardiovascular fitness
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
24. Reshape or tone my body
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
25. Improve performance for a particular sport
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
26. Improve moods and ability to cope with stress
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
27. Improve flexibility
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
28. Increase strength
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
29. Increase energy levels
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
30. Enjoyment
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
31. What types of exercise interest you?
Barriers (Place an X in the appropriate box)
32. I have no time or little time to exercise
True / False
33. I find exercise boring
True / False
34. I have found in the past, exercise has had little or no effect
True / False
35. I feel embarrassed to exercise
True / False
36. I don’t know where to start
True / False
37. I haven’t got the right equipment to exercise
True / False
38. I can’t afford gym or exercise classes
True / False
39. I feel intimidated by other gym users or equipment
True / False
40. I believe gyms are only for fit people
True / False
41. I don’t exercise as it hurts too much
True / False
Exercise goals (Place an X in the appropriate box)
42. Select the most appropriate goals to you.
weight loss / improved health
body shaping / reducing blood pressure
building muscle / lowering cholesterol level
developing strength / other (please state below)
43. How long haveyou been thinking about getting fitter?
44. What do you want exercise to do for you:
short-term (1-12 weeks)
medium-term (13-51 weeks)
long-term (more than 1year)
45. Do you consider all these goals achievable and if no, why not?