LIFESTYLE QUESTIONNAIRE

Personal Information: (Confidential – will only be used for exercise program design)

Name:_______________________________________________ Date of birth:_________________ Sex: M/F

Baby’s Name__________________________________________ Date of birth: _________________ Sex: M/F

Address: ________________________________________________________Phone (H): ________________

________________________________________P/C: ____________Mobile: ___________________

Email: ___________________________________________________________________________________

Emergency contact person: ______________________________________ Phone: _____________________

Relationship to you: _________________________ Your Occupation: ________________________________

How did you hear about us? __________________________________________________________________

Height (cm) ____________ Current Weight (kg) ____________ Goal Weight (kg) or size____________

Exercise History: Tick Dthe most correct

Do you currently engage in exercise? Yes No

If yes, how many session per week? 1-3 3-5 >5

How long on average are the session? <30min >30m &<1hr >1hr

If you engage in exercise what activities do you do?

Briefly described these activities: Tick Dthe most correct

........................................................................................... Walking Running

........................................................................................... Cycling Swimming

........................................................................................... Aerobics Weights

.......................................................................................... Other

Do you have any previous background in sporting activities? Yes No

Explain: ………………………………………………………………….

………………………………………………………………….

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Bub+Me PT
ABN: 98 871 096 119 © 2009
 Do you feel/think an exercise program will help you? Yes No
Explain: ………………………………………………………………….

………………………………………………………………….

………………………………………………………………….

Do you have any concern/queries regarding commencing a new exercise program?

Explain: …………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Listed below are several goals that can be achieved with regular exercise. How important are they to you? Rate
each one (separately), according to the scale below:

ƒ Feel Healthier

ƒ Improve Strength 1 1. Not Important

2.
ƒ Increase Muscle Size
3.
ƒ General muscle Toning 4.

ƒ Improve Aerobic Fitness 5. Important

6.
ƒ Reduce Body Fat
7.
ƒ Improve Flexibility 8.

ƒ General Fitness 9.
10. Very Important
ƒ Improve Core Strength

WHEN DO YOU PREFER TO EXERCISE? TICK DONE ONLY – OR RANK IN ORDER OF PRIORITY

MORNING <9.00AM MID MORNING >10.00AM LUNCHTIME >12.00PM AFTERNOON >2.00PM

WHAT TYPE OF EXERCISE INTERESTS YOU? TICK DAS MANY AS YOU LIKE
Other types?
…………………………………………………………………. Walking Running

…………………………………………………………………. Cycling Swimming

…………………………………………………………………. Aerobics Weights

DO YOU HAVE ANY OTHER COMMENTS / SUGGESTIONS REGARDING THE DEVELOPMENT OF YOUR EXERCISE PROGRAM?
………………………………………………………………………………………………………………………………….
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Bub+Me PT
ABN: 98 871 096 119 © 2009
Medical Questionnaire

To help us provide a quality service to you please answer all of the below questions as accurately as possible. The information obtained
will be treated in the strictest confidence and will not be released to any other person without your written consent.

Medical Practitioners Name: _____________________________________ Phone Number: ____________________

If you answer yes to any of the following questions please discuss these issue/s with the Fitness Instructor prior to
commencing any fitness activities (medical clearance may need to be sought).

Do you currently, or have you in the last 12 months suffered from? Answer
High Blood Pressure Yes / No
High Cholesterol Yes / No
Pain or Tightness in Chest Yes / No
Any Heart / Brain Condition Yes / No
Diabetes Yes / No
Epilepsy Yes / No
Liver / Kidney Condition Yes / No
Are you over 50 Yes / No
Do you experience of have you experienced? Answer
A family history of heart disease, stroke or high cholesterol of relatives under 65 years of age Yes / No
Asthma / Respiratory Condition Yes / No
A Hernia Yes / No
Arthritis of any joint pain Yes / No
Back Pain Yes / No
Muscular Pain / Cramps Yes / No
Any major injuries of hospitalizations in the last 12 months Yes / No
Do you smoke? Yes / No
Regular Headaches Yes / No
Heart beat abnormalities Yes / No
Long term Cough Yes / No
Are you taking any prescribed medication? Yes / No
Have you recently had any infectious diseases? Yes / No
Are there any conditions that may limit your exercise program that you are aware of? Yes / No
Females Answer
Are you currently pregnant or trying to conceive? Yes / No
If pregnant are you currently undertaking any regular physical activity? Yes / No
Have you given birth in the last 6 weeks? Yes / No

If your situation changes over time please advise a staff member to update our records.

PATICIPANTS DECLARATION
I have read and understand the above information and certify that the information provided on this form is accurate to the
best of my knowledge. I understand that it will be treated as confidential.
I understand that Bub+Me PT trainers are educated & trained in the field of group exercise instruction, fitness testing.
I recognise that the instructors are not medically qualified or able to provide me with medical advice. I do not hold them
responsible or liable for any indemnity, personal injury, loss or damage as a result of participating in the Bub+Me PT
program. I consider myself capable and in good health to participate in fitness training or walking.

Signature: ___________________________________________________________________ Date: ______________________

Office Use
Medical Clearance Required: Yes/No Date Medical Clearance Obtained: …………...
Bub+Me PT
ABN: 98 871 096 119 © 2009