Personal Trainer Questionnaire – Fill Out and Use This PDF

Date_____/_____/_____

PERSONAL TRAINING QUESTIONNAIRE

First Name: _________________________________Last Name: __________________________________

Address 1:______________________________________________________________________________

Address 2: _____________________________________________________________________________

City, State, Zip: ________________________________________ Date of Birth: ______/_______/_______

Phone # _______________Email:______________________________________ CWID:__________________

Affiliation: ☐ Undergrad ☐ Graduate/Doctorate ☐ Faculty/Staff ☐ Alumni ☐ Other: _______________

Emergency Contact: _______________________Relationship: _________________ Phone: _______________

1.) Please describe your current and/or previous exercise experience:

2.) How many sessions per week would you like to meet with your trainer? _______

3.) Do you plan to exercise in addition to personal training sessions? If so, how many times per week? ____

4.) Are you currently taking any over-the-counter or prescription medications or drugs? If so, please list:

5.) What are your health and fitness goals? (Check all that apply)

7.) Do you have a specific trainer in mind? ☐ Yes ☐ No If yes, please specify. _______________________

At the Department of Wellness, your safety is our primary concern. For this reason, we comply with the health and fitness standards of the American College of Sports Medicine.

On the Physical Activity Readiness Questionnaire (PAR-Q), you identified that you have one or more coronary and/or other medical risk factors which may impair your ability to exercise safely. For this reason, you need to have a physician complete and return this medical clearance form before you can begin exercising at the Seretean Wellness Center or the Colvin Recreation Center.

We recognize that you are eager to start your fitness program, and we sincerely regret any inconvenience that this may cause you. However, please keep in mind that we want your exercise experience to be as safe as possible.

Please ask your physician to complete the bottom portion of this form. He/she may fax the form back to us at the number listed below.

I hereby give my physician permission to release any pertinent medical information from any medical records to the staff at the Department of Wellness. All information will be kept confidential.

Patie t’s a e t pe or pri t __________________________________________DOB _______________

Patie t’s sig ature: ________________________________________________ Date: _______________

Reason for medical clearance _____________________________________________________________

Please return to:

Preston Nesemeier, B.S.

Fitness Coordinator

Seretean Wellness Center

Phone: 405-744-2379

Fax: 405-744-7670