C-B-C-training Consultation.

Full Name*

First NameLast Name
Email
example@example.com
Gender

MaleFemaleOther
Date of Birth*

MonthDayYear
Age
years
Height
cm
Weight
KG
What do you do for a living?
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
If you have any injuries, please list them.
Are you experiencing any stresses or motivational problems?

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

YesNo
Do any diseases run in your family?

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

YesNo
if yes please list:
Do you currently track your daily food intake?

YesNoSometimes
Are you a current cigarette smoker?

YesNo
Please rate your readiness for change.

12345678910
What following goals does best fit in with your goals?

Improved healthIncreased strengthIncreased muscle massFat lossBuild confidenceOther

TImeline for achieving your goal.

	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.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you previous Gym experience?

YesNo
If yes what kind of training did you do:
What are your expectations on me as your Personal Trainer?
Do you have access to

A fully equipped gymSome training equipment at homeNo training equipment at all
If you train from home please list equipment available to you.
1.) CANCELLATIONS Cancellations should be made at least 30 days in advance. Please note, online personal training doesn't include any one to one personal training sessions, these must be booked independently. 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!*

YesNo
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