PT Enquiry Form 1-1

Full Name

First NameLast Name

Date of Birth

MonthDayYear

Phone Number

Would you like to book a phone consultation?

Age

years

Height

cm

Weight

KG

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, afternoons or nights?

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

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

If you are on any medications, please list them.

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

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:

Please rate your readiness for change.

Which of the following best describes 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
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.

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

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?

What are your expectations on me as your Personal Trainer?

Are you ready to make the changes you have always wanted today!

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 50% 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!