bodybylulu Personal Training Application
Name
*
First Name
Last Name
Phone Number
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Instagram handle
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Ex. @bodybylulu
E-Mail
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Age
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Height
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Weight
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Current Occupation
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Do you have children?
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None
1
2
3+
FEMALES: How many weeks/months/years post-partum are you?
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Type N/A if not applicable.
What are your fitness goals?
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(Weight loss, build muscle, lower cholesterol, increase endurance, etc)
I’d like to lose _______ pounds in the next 12 weeks.
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What are you struggling with the most with that is preventing you from reaching your goal?
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For ex: Time, Nutrition, Consistency, Exercise Program, Motivation, etc.
How long have you been trying to solve this?
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Have you ever participated in a 12 Week Nutrition + Exercise Program in the past?
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Yes
No
Have you ever hired a personal trainer in the past? If so, please list their names/gyms/companies.
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On a scale of 1 to 10, how important is it for you to learn how to decrease fat, increase muscle, improve endurance/cardiovascular health, and eat properly without "dieting" in the next 12 weeks?
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Not important
1
2
3
4
5
6
7
8
9
Very important
10
1 is Not important , 10 is Very important
Are you willing to dedicate at least 3-5 hours per week for $100/session on the program?
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Yes
No
When hiring a Personal Trainer/Health Coach, what aspects are most important to you? Price or if it actually works?
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What is your CURRENT exercise routine/fitness membership?
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What was your PREVIOUS exercise routine/fitness membership?
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I’d prefer a ____________________ training program.
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High Intensity
High Intensity/Low Impact
Low Intensity/Low Impact
Weights/Strength
Post-Partum/Pelvic
No Preference
Other
Please list all of the gym equipment you own.
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For ex: yoga mat, 5 lb dumbbells, resistance band, etc
Medical History
Please list any pains/limitations/restrictions:
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Please list any surgeries:
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Are you pregnant?
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Yes
No
Do you have any of the following? (Please check all that apply)
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Herniated/Bulging Discs
Sciatica
Diastasis Recti
Urinary Incontinence
Shortness of Breath
Vertigo/Dizziness
Other
Have you ever had any of the following? (Please check all that apply)
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Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
High Cholesterol
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Other
Other illnesses:
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Please list your current medications:
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Other comments regarding your medical history:
Exercise
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Never
1-2 days per week
3-4 days per week
5+ days per week
Other
Diet & Nutrition
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I have a strict diet
I have a moderate diet
I don't have a diet plan
Other
I have the most trouble limiting my
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Carbs
Fats
Sugars
Alcohol
Other
Alcohol Consumption
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I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Other
Caffeine Consumption
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I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Other
Do you smoke?
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No
0-1 pack/day
1-2 packs/day
2+ packs/day
Other
Where did you hear about my program?
*
Instagram explore page
Instagram tag
Facebook
Friend
Other
Signature
Submit
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