Tester:

Fitness test background questionnaire

Basic information of the customer

Name: Date of birht:


Address:


Phone number: E-mail:



Heigth: Weight:

Activity level


1. Which of the following groups do you belong?
During the latest three months concider all physical exercise that has lasted at least 20 minutes.
Circle the best suiting option / options
1 Practically no physical exercise any week 2 Relaxed excersice on one or more days a week. On how many days? _______________
Fast paced exercise or muscle training 3 about once a week 4 twice a week 5 three times a week 6 at least four times a week

2. Which have been the most frequent physical activities lately?

1. _____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

3. Have you had more or less physical exercise during the latest three months compared to the time before that?
1 more excersice 2 no significant changes 3 less excersice

4. What are your current resources (time, money, locations, guidance) for physical exercise at your life situation? How interested are you in
physical exercise?
1 good resources 2 average resources 3 poor resources
1 very interested 2 somewhat interested 3 not interested


Health survey (circle the best suiting option)


5. How do you estimate the state of your health at the moment?
1 very poor 2 poor 3 average 4 good 5 very good


6. Which of the following options best describes your movement ability?
1 I can walk normally inside, putside and in stairs
2 I can walk normally inside but outside or / and in stairs I have slight difficulties
3 I can walk normally inside but outside or / and in stairs I have big difficulties

7. How do you estimate your physical condition compared to other people your age?
1 lot worse 2 somewhat worse 3 as good as theirs 4 slighty better 5 significantly better


Read the following questions carefully and answer by circling yes or no.


8. Do you have any condition diagnosed by doctor in your cardiovascular or respiratory system?

Yes No Which?:



9. Do you have chest pain or shortness of breath?
a) in rest: Yes No b) in stress: Yes No


10. Do you have hypertension or has the doctor diagnosed high blood pressure?
Yes No


11. Do you often feel dizzyness?
Yes No


12. Do you have doctors diagnose on arthritis or other joint condition with inflammation?
Yes No


13. Do you have back pain or other musculosceletal condition?
Yes No Which?:


14. Do you have some other condition (not mentioned above) that causes you limitations in taking physical exercise?
Yes No Which?:


15. Are you currently under any medication?
Yes No

If Yes, list the names of the madication, dosage and purpose of use


16. Have you during the last two weeks had any inflammation (cold, fever, etc.)
Yes No Which?:


17. Have you diring the last 24 hours consumed more than two servings of alcohol?
Yes No


18. Have you been smoking regularly during the latest 6 months?
Yes No


Signing of the questionnaire


Have you earlier taken a fitness test? Yes No
I have carefully read the questions of this questionnaire and answered to my best knowledge. Yes No
I am participating exercise / fitness test voluntarely. Yes No


Date and signature: