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?
None(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
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?
YesNo
YesNo
YesNo
if yes please list:
YesNo
low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
12345678910
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
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?
12345678910
YesNo
YesNo
If yes what kind of training did you do:
MorningMid-DayAfternoonEvening
What are your expectations on me as your Personal Trainer?
YES!!Need more information
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.
YesNo
Should be Empty: