Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Gender
Male
Female
Age
years
Date of Birth
-
Month
-
Day
Year
Height
inches
Weight
lbs
Do you currently have an injury, a movement limitation, or pain that limits your ability to exercise? (knees, back, etc.)
If you have any diagnosed health problem, please list the condition (high blood pressure, diabetes, etc.):
What are your primary fitness goals?
Fat loss
Lose inches
Muscle tone
Increased energy
Increased strength
Build confidence
Improve health
Other
How long have you been thinking about accomplishing your fitness goals?
What has prevented you from achieving your goals?
What would happen for you if you achieve your goals?
What specific body parts are you more focused on changing?
On a scale of 1 to 10 (10 being the most serious), how serious are you about accomplishing your fitness goals?
How often are you willing to train per week in order to reach your goal?
Have you ever worked with a personal trainer before?
Yes
No
If you are employed, how would you describe your activity at work?
Active
Sedentary
What can we do in order to make sure that you are successful?
Variety
Accountability
Structure
Challenge
Other
At what times during the day would you prefer to train?
Morning
Mid-day
Afternoon
Evening
How many meals are you eating daily?
1
2
3
4
5
Other
What is your biggest nutritional challenge?
Cravings
Eating out frequently
Time to prep meals
Emotional/Stress eating
Alcohol
Not knowing what to eat
Other
How many times per week do you eat out?
1 to 3
4 to 6
Almost daily
Everyday
Other
Does your spouse or family support your health and fitness journey?
Yes
No
Are there any specific events coming up that will help us motivate you to reach your goals?
Birthday
Wedding
Anniversary
Vacation
Reunion
Other
Signature
Submit
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