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.

Section 1: Client Information

  First Name:      Last Name:   

  University ID:

  University Status :   (Click here for more information)

  Personal Training Package Selection:

  Date of Birth (mm/dd/yy):      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 select the "Yes" to any of the question that may apply to you. Please ask if you have any questions.

Medical Screening

  Do you have any personal history of heart disease (coronary or atherosclerotic disease)?

  Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?

  Any personal history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?

  Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?

  Any unaccustomed shortness of breath (perhaps during light exercise)?

  Have you had any problems with dizziness or fainting?

  Do you have difficulty breathing while standing or sudden breathing problems at night?

  Have you experienced a rapid throbbing or fluttering of the heart?

  Do you suffer from ankle edema (swelling of the ankles)?

  Have you experienced severe pain in leg muscles during walking?

  Do you have a known heart murmur?

  Has your serum cholesterol been measured at greater than 200 mg/dl?

  Are you a cigarette smoker?

  Has your HDL (the "good" cholesterol) been measured at greater than 60 mg/dl?

  Would you characterize your lifestyle as "sedentary"?

  Have you had a high fasting blood glucose level on 2 or more occasions (>=110mg/dl)?

  Are you 20% or more overweight or have you been told your "BMI" was greater than 30?

  Have you been assessed as hypertensive on at least 2 occasions (systolic > 140 mmHg or diastolic > 90mmHg)?

  Do you have any family history of cardiac or pulmonary disease prior to age 55?

Detailed Medical History

Are you currently being treated for high blood pressure?  

If you know your average blood pressure, please enter:

Please check all conditions or diagnoses that apply:

























  
                            

Has a doctor imposed any activity restrictions? If so, please describe:  

 

 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

Are you a smoker?        If so, how many per day?

Are you a previous smoker?        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 :

Do you drink alcoholic beverages?      

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.






  
                            

Section 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?   (1 = Very Easy and 10 = Very Intense)

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

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

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:















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?   (1 = Not Very Motivated and 10 = Very Motivated)

6. What is your level of confidence?   (1 = Not Very Confident and 10 = Very Confident)

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? (minutes)

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

  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!