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 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):




Please Select Any Medications You Are Currently Using:



Please list the specific medications that you currently take:




      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
1/2 pint of beer
1 glass of wine
1 pub measure of spirits (Gin,Vodka etc.) 1
1 can of beer
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:
Racquet Sports:
Stair Climbing:
Weight Training:
Yoga/Martial Arts:


Activity Interests and Preferences


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

Step Aerobics




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




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?





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!