Full Name
*
First Name
Last Name
Gender
Male
Female
Age
years
Height
cm
Weight
KG
What do you do for a living?
Does your occupation require repetitive movements? (If YES, please explain.)
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
What is your general physical activity level?
Sedentary
Light (1-2 days per week)
Moderate (3-5 days per week)
Heavy (6-7 days per week)
2 times per day
What are your goals (in terms of exercise)?
ex: lose weight, build muscle, learn balanced routine
What are your physical limitations?
ex: achey knees, prior injury, low impact
What are your most and least favorite exercises?
Physical Activity Readiness
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?
Yes
No
In the past month, have you had chest pain when you were not performing any physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Yes
No
Do you know of any other reason why you should not engage in physical activity?
Yes
No
Medical
Have you ever had any injuries or chronic pain? (If YES, please explain.)
Have you ever had any surgeries? (If YES, please explain.)
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease,hypertension, high cholesterol, or diabetes? (If YES, please explain.)
Are you a current cigarette smoker?
Yes
No
What following goals best fit in with your goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
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.
1
2
3
4
5
6
7
8
9
10
Have you trained with a personal trainer before?
Yes
No
If yes what kind of training did you do:
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 Select
1 Session
2 Sessions
3 Sessions
4 Sessions
5 Sessions
6 Sessions
7 Sessions
Please Choose
What are your expectations on me as your Personal Trainer?
Submit
Should be Empty: