Personal Training Consultation Questionnaire

Full Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender

Male Female
Date of Birth

Month Day Year
Age
years
Height
Weight
How do you rate your average daily physical activity level?

none (mostly seated) Moderate (light activity such as walking) High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights? If yes, what do you do?
How often do you travel?

Rarely A few times a year A few times a month Weekly
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 current injuries, please list them.
What additional therapies are being undertaken for the given injury?
Did you have any surgeries and/or injuries in the past? If yes, please list them.
Do you wear glasses or contact lenses?
Do you have any loss of hearing, decreased or loss of sense of smell/taste? Do you have any numbness or loss of sensation in any part of your body?
Do you have any scars or tattoos?
Are you a current cigarette smoker?

Yes No
Your current diet could be best characterized as:

Low-fat Low-carb High-protein Vegetarian/Vegan Ketogenic
Please rate your readiness for change. (1 is the lowest)

1 2 3 4 5 6 7 8 9 10
What following goals does best fit in with your goals?

Improved health Improved endurance Increased strength Increased muscle mass Fat loss Improved balance More flexibility Pain reduction Better coordination
What is your goal for working with a personal trainer?
How many days and for how long are you planning to workout per week?
Please rate your motivational level to do what it takes for reach your goal. (1 is the lowest)

1 2 3 4 5 6 7 8 9 10
Are you currently excersising regulary (at least 3x per week)?

Yes No
Have you trained with a personal trainer before?

Yes No
If yes, what kind of training did you do or like?
At what times during the day would you prefer to train?

Morning Mid-Day Afternoon Evening
How often do you want to do personal training a week?
Please Choose
Do you consider online training?
What kind of equipment do you have available?
What do you do for fun?
Emergency contact

First Name Last Name
Phone number of your emergency contact

Area Code Phone Number
1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

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! *

Yes No
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