PT Assessment Form Name * First Name Last Name Date * MM DD YYYY Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Gender * Male Female Height * Weight * What are your fitness goals? * What is the timeframe for reaching your fitness goals? * When was the last time you had a physical examination? * Are you currently under a doctor's care? * Yes No If yes, please explain: Have you been recently hospitalized? * Yes No If yes, please explain: Do you take any medications on a regular basis? * Yes No If yes, please list medications and reasons for taking: Do you have any of the following? High blood pressure High cholesterol Diabetes Have you or your parents/siblings, prior to age 55, had any of the following? A heart attack A stroke High blood pressure Do any of the following apply to you? Drink alcohol more than three times/wk Drink soda/energy drinks more than three times/wk Smoke Drink coffee Have a high stress level Have you ever had an exercise stress test? Yes No Don't Know If yes, the results were: Normal Abnormal Have you ever done any of the following? Participated in a structured exercise training program Worked with a Nutritionist Worked with a Certified Personal Trainer How would you describe your current exercise routine or level of activity most days? * How would you rate your motivation toward exercise? 1 - Unmotivated 2 - Somewhat Unmotivated 3 - Somewhat Motivated 4 - Very Motivated Realistically, how many days are you available to exercise per week (including sessions with a trainer and without a trainer) 1 day/wk 2 days/wk 3 days/wk 4 days/wk 5 days/wk 6 days/wk Thank you!
