Personal Training Consultation Questionnaire

Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Height*
feet/inches
Weight*
LBS
Phone Number*
Email *
Social Media: Instagram/Facebook link or name.
How Did you hear about TJTemperTraining?*

Social MediaReferralPure Heart ChurchPrevious Client
Do you have any diagnosed health problems or injuries list the condition(s).*
What is your Goal? Lose 10lbs, Gain 10lbs of muscle, Look good, feel better, Have more energy? Please be specific. Does not have to be a physical goal. *
What's stopping you from hitting your goals? *
Are you experiencing any stresses or motivational problems?*

YesNo
if yes please list:
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
if yes please list:
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Please rate your readiness for change.*

12345678910
What following goals best fit in with your goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss

TImeline for achieving your goal.*

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

Please rate your motivational level to do what it takes to reach your goal.*

12345678910
Are you currently excersising regulary (at least 3x per week)?*

YesNo
Have you trained with a personal trainer before?*

YesNo
If yes what kind of training did you do:*
At what times during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?*
Please Choose
Do you have family and friends that support you ( Meaning they will give you a thumbs up on whatever you decide)? *
Terms and Conditions

1.) 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: