Pre-Consultation Form

1
First things first! What is your name?* This field is required.
First Name
Last Name
2
Email address* This field is required.
example@example.com
3
Phone number
4
What is your age range?* This field is required.
0-17
18-24
25-34
35-44
45-54
55-64
65+
5
How long have you been wanting to make changes to your lifestyle?* This field is required.
6 months
1-2 years
2-3 years
5+ years
Other
6
How important is it for you to make these changes?* This field is required.
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2
3
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9
10
Not important
Very important
7
Please explain in more detail why you chose that answer.* This field is required.
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8
Have you ever set your own goals before and if so, what were they?* This field is required.
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9
Did you achieve them?* This field is required.
Yes
Some results
No
10
When working towards your goals, what were the main barriers you had to try to overcome?* This field is required.Please select all that apply
Time
Knowledge
How to apply the knowledge
Motivation
Unsustainable process
Social life/work lifestyle
Family
Other
11
How would you rate your current activity levels?* This field is required.
Sedentary – (Little to no daily walks, desk job little to no exercise)
Lightly active – (Lightly active plus exercise 1-3 times per week)
Moderately active – (Moderate daily walks/activity plus exercise 3-5 times per week)
Very Active – (Highly active with walks/daily activity and exercise 5-7 times per week)
12
How would you rate/describe your current nutrition?* This field is required.
Terrible all of the time
Not great really - more 'bad' than good
Not too bad - decent through the week but go mad at weekends
I’m pretty good most of the time but don’t see many results from that
All over it! Understand calories know what and how much to eat
13
Please explain in more detail why you chose that answer.* This field is required.
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14
What is your present gym experience?Please select all that apply
Use fixed pin weight machines
Use free weights
Use cardio kit
Use classes
Daily walks
Home workouts
Other
15
When it comes to the gym, exercise and movement, what do you enjoy to do?
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16
What do you find you dislike and don't enjoy?
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17
Imagine we are having this conversation a year from now and we are looking back over our time together. What has to have happened for this to be the best investment you have ever made in your health and fitness?
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18
What days and times are you available for personal training sessions? (Tick all that you could reasonably do with your schedule).* This field is required.Saturday morning (Small Group Training) is also available.
12:00pm
1:00pm
2:00pm
3:30pm
4:30pm
5:30pm
6:30pm
Monday
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Tuesday
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Wednesday
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Thursday
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Monday
Tuesday
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Thursday
12:00pm
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1:00pm
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2:00pm
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3:30pm
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4:30pm
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5:30pm
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6:30pm
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12:00pm
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1:00pm
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2:00pm
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3:30pm
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4:30pm
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5:30pm
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6:30pm
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12:00pm
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1:00pm
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2:00pm
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3:30pm
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4:30pm
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5:30pm
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6:30pm
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12:00pm
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1:00pm
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2:00pm
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3:30pm
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4:30pm
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5:30pm
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6:30pm
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19
How did you hear about me/find me?
Pure Gym website
Pure Gym PT Board (in Gym)
Search engine (Google, Yahoo etc)
Recommended by friend, gym member, client etc.
Weightlifting Workshop
Other
20
Do you want to add anything else you feel would benefit my understanding of you and what you want to achieve?
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