Personal Training Consultation Questionnaire

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

years

Height

IN

Weight

LBS

What do you do for a living?

Whats the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

Please list the physical activities that you participate in outside of the gym and outside of work:

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

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

Do any diseases run in your family?

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

if yes please list:

Are you a current cigarette smoker?

Your current diet could be best characterized as:

What following goals best fit in with your goals?

What is your goal with your training?

Why?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
Select One:

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.

Are you currently exercising regularly (at least 3x per week)?

Are you looking for nutrition coaching?

Have you trained with a personal trainer before?

If yes what kind of training did you do:

At what times during the day would you prefer to train?

How often do you want to train per week?

Please Choose

Signature

Name

First NameLast Name

What are you looking for in a trainer?

1.) PAYMENTS:

If we decide we are a good fit for each other, payment is to be recieved in order for you program to be delivered.

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!