Online Personal Training Consultation Form

Online Personal Training Consultation Questionnaire
Full Name*

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

Once onboarding has been completed, due to the amount of work needed to be completed, no refunds will be issued.

If you would like to cancel, we require 1 months notice following the initial period above being completed.

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.