XCELL PERFORMANCE GROUP

Health and Lifestyle Questionnaire

Please fill out the following information and I will be in contact with you shortly.

First Name:
Last Name:
Email:
Phone:
Date of Birth:

When was the last time you had a physical examination?
Have you had your cholesterol checked within the past year? Results?	Yes No
Are you currently on any medications?	Yes No
Has your doctor ever diagnosed you as having heart disease, stroke, diabetes or epilepsy?	Yes No
Has a parent, brother, sister ever been diagnosed with heart disease?	Yes No
Do you have any back problems, arthritis or any orthopedic problems?	Yes No
Any other medical concerns?	Yes No

Have you ever used a personal trainer before?	Yes No
What is your current activity level? Per week.
Do you smoke? How much?	Yes No
Do you consume alcoholic beverages? How much per week?	Yes No
How much caffeine do you consume in a day?
How much water do you drink in a day?
Do you eat breakfast?	Yes No
Describe your stress level
What motivated you to consult with a personal trainer?
What are your goals? What do you hope to accomplish by working with a trainer?
Short Term Goals:
Long Term Goals:

What types of exercise do you like to do?
What types don’t you enjoy?
How often do you plan on exercising?
What are you biggest obstacles which may prevent you from achieving your goals?
What day(s) off would you prefer?