Full Name
*
First Name
Last Name
Gender
Male
Female
Age
years
Height
cm
Weight
KG
What do you do for a living?
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work.:
Are you a smoker?
Yes
No
What is your goal?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
What have you tried before?
WW
Keto
Juice Plus
Clean 9
Intermittent Fasting
Calorie Counting
Slimming World
Other (please specify)
What is your ultimate long term goal?
Why?
What’s stopping you achieve your goal?
TImeline for achieving your goal.
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
Please rate your motivational level to do what it takes for reach your goal.
1
2
3
4
5
6
7
8
9
10
How many times a week do you currently exercise?
1-2 times
2-3 times
3-5 times
I don’t
How many times a week are you prepared to exercise?
1-2 times
2-3 times
3-5 times
Have you trained with a personal trainer before?
Yes
No
If yes what kind of training did you do:
How would you prefer to train?
Group exercise
1-1 sessions
Mixture of both
At what times during the day would you prefer to train?
Morning
Afternoon
Evening
How is best for me to contact you?
Phone
Email:
Submit
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