Viterbo University - The University of Opportunity: Hope and Help

 
 

Personal Training and Fitness Assessment Program

Personal Training is free to all Viterbo students. Fees apply to all other members. Click here for the personal training fee schedule.

The information provided will help the personal trainers best serve you as well as to track your progress with our program. There are three sections to this form: the client information, the medical/health history questionnaire, and exercise history/activity preferences. Please answer each of these questions as accurately as you can. Should you have any questions, feel free to ask us at wellness@viterbo.edu or 608-796-3121. Your responses will be treated in a confidential manner.


 

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Section 1: Client Information

First Name:    Last Name:   
 

University ID:   University Status (Click here for more information):
 

Personal Training Package Selection:
 

Date of Birth:    Gender:
 

Street Address:  City:  
 

State:    Zip Code:
 

Email:    Phone:    Alternate Phone:
 

Emergency Contact:    Phone:  
 

Doctor or Clinic:     Phone:  


 

Section 2: Medical / Health Status Questionnaire

On this questionnaire, a number of questions regarding your physical health are to be answered. Please answer every question as accurately as possible so that a correct assessment can be made. Please place a check in the space to the left of the question to answer "Yes." Leave blank if your answer is "No."Please ask if you have any questions.

Medical Screening

 

 

 

 

 

 




























 

Detailed Medical History


            If you know your average blood pressure, please enter:  

Please check all conditions or diagnoses that apply:
 

        
        
        
        
        
        
        
        
      

 
 

 

 


 

 Family History

 

Have your mother, father, or siblings suffered from (please select all that apply):
 

   
     
     
     
     

 

Medications

Please Select Any Medications You Are Currently Using:
 

    
     
     
     
     

 

Please list the specific medications that you currently take:

  
 


 

Lifestyle

      If so, how many per day?  

   If so, when did you quit?  

How many years have you smoked or did you smoke before quitting?  

Do you smoke:

       

 

Please Rate Your Daily Stress Levels (select one):

 

  

 

    
 

If so, how many units of alcohol do you consumer per week? 
(see Alcohol Units Chart) 

Alcohol Unit Chart 

 

Type of Drink
 
Units
 
1/2 pint of beer
 
1
 
1 glass of wine
 
1
 
1 pub measure of spirits (Gin,Vodka etc.) 1
1 can of beer
 
1.5
 
1 bottle of strong lager 2.5
1 can of strong lager 4
1 bottle of wine 7
1 litre bottle of wine 10
1 bottle of fortified wine (port,sherry etc.) 14
1 bottle of spirits 30

 


 

Dietary Habits. Please Select All That Apply.

 

    
     
     

 

Part 3: Exercise Habits and Activity Preferences

Exercise History

On average, how many times do you exercise per week?
 

On average, how long do you exercise per session (in minutes)?
 

On a scale from 1 to 10, how intense is your typical workout?
Very Easy 1 2 3 4 5 6 7 8 9 10 Very Intense
 

For each activity in which you participate, indicate your typical exercise in minutes:

 

Aerobic Classes:
 
Cycling/Spinning:
 
Racquet Sports:
 
Running/Jogging:
 
Snowboard/Skiing:
 
Stair Climbing:
 
Swimming:
 
Walking:
 
Weight Training:
 
Yoga/Martial Arts:
 
Other:  
 

 

Activity Interests and Preferences

 

   Aerobic Classes
 
   Free Weights
 
   Golf
   Group Activities
 
   Indoor Cycling/Spinning
 
   Outdoor Cycling
 
   Running
 

  
Step Aerobics
 
   Swimming
   Tennis
   Walking

 

 

Other:
 


Personal Fitness & Lifestyle Goals

In striving to achieve a higher state of wellness or fitness, a set of clearly articulated goals is essential.These goals will help to guide your lifestyle choices such as when and what to eat, how often and how intensely to exercise, and how to overcome the challenges and barriers you will surely encounter.

1. Please indicate all of your personal health and fitness goals:
 

 

  Lose Weight
 
   Improve Flexibility
 
   Reduce Back Pain
 
   Stop Smoking
 
   Reduce Stress
 
   Improve Diet
 
   Feel Better
 
   Lower Cholesterol
 
   Aerobic Fitness
 
   General Fitness
 
   Muscular Strength
 
   Muscular Size
 
   Sport Specific
 
  Injury Rehab
 
   Look Better
 

 

 

Other:
 

2. What other health improvements do you want?
 

3. What other health improvements do you need?
 

4. What are your barriers to success?
 

5. What is your motivation level?
 

6. What is your level of confidence?  

7. What do you consider evidence of your success?
 

8. Three concrete commitments to help you reach your goals.
 

 

Program Considerations

 

1. How many days per week do you want to commit to exercising? 
 

2. How much time can you devote to each workout?
 

3. How much time can you devote to each personal training session?
 

4. What days and times can you typically meet?
 

5. Are you comfortable using free weights?
 


 

 

Other

 

Please indicate any other Medical Conditions that you may have. It is important that this information be as accurate and complete as possible.


 


 

Please indicate any other Activity Restrictions that you may have.


 


 

 Thank you for taking the time to complete this form and questionnaire!