Request Consultation - Free Health & Fitness Assessment

Complete this form for your free in-home consultation!
Or schedule by phone, Mondays through Fridays from 8am to 8pm Eastern, 10am to 6pm Saturdays

Email: *

Cell Phone or Home Phone: *

Street Address:

* Required fields.
Zip code is used to find trainers near you.

Full Name: *

Work Phone:

City:

State:

Zip: *

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The health questions below are required for your consultation.


Birthdate: Height: Primary Physician Name: Primary Physician Phone: Include area code	Gender: Male Female Weight: Emergency Contact Name: Emergency Contact Phone: Include area code

Have you ever suffered a definite or suspected stroke?		Yes No
Have you had coronary bypass surgery or any other heart surgery?		Yes No
Do you have any other cardiovascular or pulmonary (lung) disease other than asthma, allergies, or mitral valve prolapse?		Yes No

Within the past 12 months, has a health professional told you that you have high blood pressure? Definition: Systolic >=140 or diastolic >=90		Yes No
Have you taken any medications to control your blood pressure in the past 12 months?		Yes No
Do you have a heart murmur, or an abnormal resting or exercise (treadmill) EKG?		Yes No
Do you have pain or discomfort in the chest or surrounding areas when you engage in physical activity?		Yes No
Do you experience difficulty breathing, unexplained dizziness, fainting, or recurrent swelling of the ankles (unrelated to injury)?		Yes No
When not in the upright position, do you have difficulty breathing at night?		Yes No
Do you experience any pain in the legs that would cause you to stop walking (claudication)?		Yes No
Do you experience heart palpitations (irregularity or racing of the heart)		Yes No

Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?		Yes No
Are you under treatment for blood clots?		Yes No
Have your father or brother had heart disease prior to age 55? Or, have your mother or sister had heart disease prior to age 65?		Yes No

If a health professional has set any limits or restrictions on your physical activity, then please describe those.

Do you have a history of diabetes, thyroid disease, kidney disease, or liver disease? Please be specific.

Is it possible that you are pregnant? If yes, what is your expected due date?

Have you been diagnosed with fibromyalgia, or suffered from any other bone, joint, or muscle issue that may be aggravated with exercise? Please explain.

Describe any back or neck problems that you have and their approximate frequency.

Have you been a cigarette smoker within the past six months? If so, then please explain.

Do you have any other conditions that may hinder your ability to exercise?
Examples are asthma, mitral valve prolapse, epilepsy, history of rheumatic fever, cancer, anemia, hepatitis or other such conditions.

If you have experienced any sudden, unexplained weight loss or weight gain at any time in the past six months, then please describe.

Have you had any surgery or been diagnosed with any disease in the past three months?

Are you currently being treated for any other medical condition?

Please list all prescriptions and over-the-counter medications that you are currently taking. List dosage and frequency of use.

Were you prescribed any medicines that you are not taking? If so, then please list them and their prescribed dosages.

If the above information is accurate and you knowingly assume the risks for injury or death associated with exercise, then confirm by entering your name and today's date. This authorizes Perfect Personal Training to discuss your medical conditions with your physician.

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The fields below are helpful to your trainer, but optional.

Over the past 90 days, roughly how often have you exercised?

How would you describe your attitude towards exercise, in general?

Do you consider yourself to be someone who has a hard time sticking with an exercise regimen?

What will happen to you if you decide not to begin health & fitness training? Consider both physical and psychological repercussions.

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The fields below are optional, but helpful for ideal trainer selection.

Do you have a preference regarding the gender of your fitness professional?

If a trainer of that gender is not available, will you be willing to train with a fitness professional of the opposite gender?

Are you interested in Training for Two or Group Sessions?

If you decide to begin fitness training, what are the most ideal days of the week and starting times for your 55-minute sessions? (use AM/PM)
Ex: Mon, Wed, Fri between 5:30PM & 7:30PM

If we cannot meet the schedule described above, then please offer alternative starting times and days of the week for your sessions. (use AM/PM)
Ex: Tues & Thurs between 5PM & 7PM; Sat between NOON & 4PM
Ex2: Mon, Wed, Fri between 6AM & 7AM

What qualities would best describe the ideal fitness professional for you?

What would you most like to achieve through fitness training and nutrition consulting?

Please enter any special concerns, questions, or additional notes here. If the location in which you'd like training is not your home, then please enter the correct zip code and/or location here.