Confidential Pre-Training Assessment

Physical Evaluation & Health Screening

Before we begin your fitness journey, please complete this comprehensive health screening so we can design a safe, effective, and personalized training program just for you.

Health Screening Questionnaire

All information shared is strictly confidential and used solely for designing your training program. Please answer each question honestly.

Personal Information

Tell us a bit about yourself so we can stay in touch.

Full Name *

Age *

Gender *

Address *

Phone Number *

Email *

Health & Exercise History

Questions 1–10: Help us understand your activity background.

1. How often do you currently exercise per week? *

None

1-2 days

3-4 days

5+ days

2. What types of exercise do you currently do? (cardio, weights, yoga, sports, etc.)

3. What are your primary fitness goals? *

4. How would you describe your overall daily activity level? *

Sedentary (mostly sitting)

Lightly active (occasional walking)

Moderately active (regular movement)

Very active (physical job/training daily)

5. Have you worked with a personal trainer before? If yes, please describe your experience.

6. Describe your athletic or sports background, if any.

7. On average, how many hours of sleep do you get per night? *

Less than 5

5-6

7-8

8. How would you rate your current stress level? *

Low

Moderate

High

Very High

9. Briefly describe your typical daily diet.

10. How much water do you typically drink per day?

Current & Past Injuries

Questions 11–18: Help us train around any limitations safely.

11. Do you have any current injuries we should know about? Please describe in detail.

12. Do you experience any chronic pain (e.g., recurring or persistent for 3+ months)?

13. List any past surgeries or major medical procedures (with approximate dates).

14. Do you have any joint issues or arthritis (knees, hips, shoulders, etc.)?

15. Have you ever had back, neck, or spinal issues (herniated disc, sciatica, etc.)?

16. Have you had any injuries in the past 12 months (sprains, strains, fractures, etc.)?

17. Are there any movements or exercises you've been told to avoid?

18. Do you experience pain during physical activity? *

Never

Occasionally

Frequently / Always

Medical Conditions & Medications

Questions 19–25: Critical health information for safe training.

19. Do you have any heart conditions or cardiovascular concerns? Please explain.

20. Do you have high or low blood pressure? *

Normal

High

Low

Unsure

21. Do you have diabetes or any blood sugar regulation issues?

22. Do you have asthma or any respiratory conditions?

23. List all current medications (prescription and over-the-counter), including dosages.

24. List any vitamins, supplements, or performance-enhancing products you take.

25. Has a doctor ever advised you to limit physical activity, OR do you need medical clearance before exercising? *

No, I'm cleared to exercise

Yes, with restrictions

Unsure / Need to check

I certify that the information provided above is accurate to the best of my knowledge. I understand that this screening helps KeishanElliottCPT design a safe training program, but does not replace medical advice. I agree to consult my physician before beginning a new exercise regimen if I have any health concerns. *

Your information is kept strictly confidential and used only to create your personalized training plan.

KeishanElliottCPT

Master Fitness Professional

Transform your health with over 30 years of expert fitness coaching. Specializing in pain-free movement and functional mobility.

NSCA-CPT, TSAC-F, ACSM-EIM 1

DOE Vendor # STR068247

Stretchprotherapy LLC • EIN 33-3068247

www.stretchprotherapy.com

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