!
!
In order for us to have a better understanding of what type of program you are
looking for, please complete the following 5-minute 50 Point Health
Questionnaire below. After you submit the form you can expect a phone call or
email within 24 hours to set up your complimentary fitness consultation!
Health Questionnaire



Name:

Phone # (day/evening):

Email Address:

Birthdate:

Male or Female:

Height

Weight:

Optimal Time to Exercise:

Occupation:

How did you hear about us:
Which program are you most interested in finding out more about:
Please check the box to the left of the condition if you have any of the following:  
Heart Disease

Pulmonary Disease

Metabolic Disease

Family History of Heart Disease

High Blood Pressure

High Cholesterol

Smoking

Sedentary Lifestyle

Chest Pain

Dizziness

Shortness of Breath

Irregular/Accelerated Heart Rate

Osteoporosis
Are you over 69 and not used to being active?

Is your physician prescribing medication for a blood pressure or heart condition?

Has a physician ever told you that you have a bone or joint problem that will
worsen with exercise?
Do you know of any reason why you should not participate in physical activity?
How many days a week are you currently working out? (0-7x)
How long are your typical workouts? (ie. 30 minutes weights/ 30 minutes cardio, etc)
How many days a week would you realistically like to see yourself working out?
Describe Your Ideal Personal Trainer (personality, special interests, etc.)
What Are Your Fitness Goals (weight loss, definition, energy gain, etc.)
What are your interests (running, biking, swimming, etc)
Why should you be chosen as a candidate to work with us at the Studio?
Congratulations! If you’ve made it this far you are well on your way to achieving
any goals that you have set for yourself. Your determination and the correct
exercise program will keep you motivated and attaining your goals!
Arthritis/ Joint Pain

Back Pain/Spine Disorder

Musculoskeletal Pain/ Injury

Hernia

Surgery

Other

Hypoglycemia

G.I. Disorder

High Triglycerides

Cancer

Pre/Postnatal

Anemia

Food Allergies
Get Started!
You've taken the 1st step toward achieving all of your health & fitness goals!
Personal Trainer Boston's training sessions are by appointment only and clients
are selected through this online health questionnaire application.
Personal Trainer Boston by Stephen Cabral
Boston's #1 Resource for Personal Training!
Guaranteed Results!
* Boston's Best Personal Trainers
* Comprehensive Evaluations
* Individualized Workout Programs
* Complete Nutritional Plans
     * Lifestyle Strategies
        * 307pg Fatlossity System
Let's Get Started!
Please fill in as much information as possible to allow us to have the best possible
picture of how we can help you achieve your goals.
Personal Trainer Boston                                                               results@personaltrainerboston.com
                                                                                                                                                                     617-426-0008