Virtual Personal Training Consultation Form

Online Personal Training Consultation Questionnaire
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
cm
Weight*
KG
Part 2. Lifestyle Information
What do you do for a living?*
Whats the activity level at your job?*

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, afternoon or nights?*
Do you attend a gym currently*

Yes gym use onlyYes classes onlyYes access to gym and classes
Please list the physical activities that you participate in outside of the gym and outside of work.:
Part 3. Medical and health information
If you have any diagnosed health problems list the condition(s).*
If you are on any medications, please list them.*
What additional therapies are being undertaken for the given health problem(s)?*
If you have any injuries, please list them.*
What additional therapies are being undertaken for the given injury?*
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
If yes please list*
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
if yes please list:*
Are you a current cigarette smoker?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Part 4. Goals
Please rate your readiness for change.*

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

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?*
Why?*

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

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 trained with a personal trainer before?*

YesNo
If yes what kind of training did you do:*
Please Read The Following Terms and Conditions.
1.) CANCELLATIONS

You agree to commit to a minimum of 3 months (12 weeks) with a virtual personal trainer. You understand leaving the service within this period will incur a charge of the remaining balance of the duration left.

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!*

YesNo
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Online Personal Training Consultation Questionnaire

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Please Read The Following Terms and Conditions.