bodybylulu Personal Training Application

bodybylulu Personal Training Application
Name*

First NameLast Name
Phone Number*
Format: 000-000-0000.
Instagram handle*
Ex. @bodybylulu
E-Mail*
Age*
Height*
Weight*
Current Occupation*
Do you have children?*

None123+
FEMALES: How many weeks/months/years post-partum are you?*
Type N/A if not applicable.
What are your fitness goals?*
(Weight loss, build muscle, lower cholesterol, increase endurance, etc)
I’d like to lose _______ pounds in the next 12 weeks.*
What are you struggling with the most with that is preventing you from reaching your goal?*
For ex: Time, Nutrition, Consistency, Exercise Program, Motivation, etc.
How long have you been trying to solve this?*
Have you ever participated in a 12 Week Nutrition + Exercise Program in the past?*

YesNo
Have you ever hired a personal trainer in the past? If so, please list their names/gyms/companies.*
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?*

1

2

3

4

5

6

7

8

9

10

1 is Not important , 10 is Very important
Are you willing to dedicate at least 3-5 hours per week for $125/session on the program?*

YesNo
When hiring a Personal Trainer/Health Coach, what aspects are most important to you? Price or if it actually works?*
What is your CURRENT exercise routine/fitness membership?*
What was your PREVIOUS exercise routine/fitness membership?*
I’d prefer a ____________________ training program.*

High IntensityHigh Intensity/Low ImpactLow Intensity/Low ImpactWeights/StrengthPost-Partum/PelvicNo PreferenceOther
Please list all of the gym equipment you own.*
For ex: yoga mat, 5 lb dumbbells, resistance band, etc
Medical History
Please list any pains/limitations/restrictions:*
Please list any surgeries:*
Are you pregnant?*

YesNo
Do you have any of the following? (Please check all that apply)*

Herniated/Bulging DiscsSciaticaDiastasis RectiUrinary IncontinenceShortness of BreathVertigo/DizzinessOther
Have you ever had any of the following? (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureHigh CholesterolDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaOther
Other illnesses:*
Please list your current medications:*
Other comments regarding your medical history:
Exercise*

Never1-2 days per week3-4 days per week5+ days per weekOther
Diet & Nutrition*

I have a strict dietI have a moderate dietI don't have a diet planOther
I have the most trouble limiting my*

CarbsFatsSugarsAlcoholOther
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/dayOther
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/dayOther
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/dayOther
Where did you hear about my program?*

Instagram explore pageInstagram tagFacebookFriendOther
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bodybylulu Personal Training Application

Medical History