Personal Training Consultation Questionnaire

Full Name*

First NameLast Name
Gender

MaleFemale
Mobile number
mobile number
Email
example@example.com
Date of Birth*

MonthDayYear
Age
years
Occupation
Do you currently exercise? if so, how often?
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
If you have any injuries, please list them.
Are you experiencing any stresses or motivational problems?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
if yes please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
Other goals

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Have you trained with a personal trainer before?

YesNo
What are your expectations on me as your Personal Trainer?
1.) CANCELLATIONS

Cancellations should be made at least 1 WEEK in advance.

2.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Should be Empty: