Online Fitness Analysis  
 
Personal History Questionnaire
The following questions are designed to help Fitness Industry Register evaluate your Health fitness needs, however, we also recognize and respect your need for privacy. Please feel free to omit any information that you may feel uncomfortable about sharing.
* Indicates Required Field
*First Name *Last Name
*Address *City
*State/Province/County *Country
*Postal Code *Email
*Telephone Work Phone
Mobile/Cell Age
   
Gender Male
  Female
 
 
   
Height Weight
   
Activity Level  
 
   
Goals/Aims  
   
Medical Questions  
   
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
   
Do you feel pain in your chest when you do physical activity?
   
In the past month, have you had chest pain when you were doing physical activity?
   
Do you lose your balance because of dizziness or do you ever lose consciousness?
   
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
   
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
   
Do you know of any other reason why you should not do physical activity?
   
About Your Practitioner  
   
Would you prefer a male or female Practitioner?

   
Please give a short description of what you require in a Practitioner
   
Lifestyle Questions  
   
Occupation How do you spend the majority of
your time at work?  
   
Do you smoke?
   
If yes, how many per day?
 
   
How would you rate your current How much water do you consume daily?
eating habits?
   
How would you like to change your current eating habits?
   
Training Details  
   
How long have you been training? How often do you train?
   
How long is each training session? What time of day do you usually train?
   
What sports do you particpate in?
Do you want your
training to be home
or gym based?
   
Training Goals  
   
Please select one of the training programmes that best describes your goals
   
Are their any body parts in particular that you wish to train?
   
Please describe your current knowledge of exercise and weight training
   
If you have a good knowledge of exercise and weight training, please best describe your current training routine
   
Areas of expertise
Acupuncture Aerobics Aromatherapy
Athletics Body Massage Bodybuilding
Boxing Cardio Caving
Chiropractor Circuits Core Stability
Cycling Dance Dietician
Equestrian Fencing Fitness
Fitness Camps Flexi Bar Football
Golf Gymnastics Hang Gliding
Health Club Hockey Juvenile
Keep Fit Lifestyle Consultant Marathon
Martial Arts Meditation Motor Sports
Mountain
      Expedition		 Nutrition Outdoor Work
Personal practitioner Physiotherapist Pilates
Pre Post Natal Reflexology Resistance Training
Rock Climbing Rowing Rugby
Running Senior Citizens Skiing
      Snowboarding
Skydiving Sports Injury Step
Strongman
      Training		 Swimming Swiss Ball
Tai Chi Tennis Triathlon Iron Man
Weight
      Management		 Weight Training Yoga
Youth Obesity Other:  
   
Terms and Conditions  
   

Fitness Industry Register shall have no liability for any injury, illness or similar difficulty that arises out of or connected with any instructions or guidance provided by any Health and Fitness Professionals provided by us.

Fitness Industry Register assumes you have had medical clearance and doctors consent to participate in an exercise program. You must agree that you assume the risks associated with any and all activities and/or exercises in which you participate.
   
  I accept the above terms and conditions