Full Name
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First Name
Last Name
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Best time to call:
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Year
Age
*
Height
*
Current Weight
*
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?
*
How often do you travel?
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Rarely
A few times a year
A few times a month
Weekly
Other
Please list the physical activities that you participate in outside of the gym and outside of work.:
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If you have any diagnosed health problems list the condition(s).
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Please be specific
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.
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What additional therapies are being undertaken for the given injury?
When was the last time you were genuinely happy? Why?
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Are you experiencing any stresses or motivational problems?
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Yes
No
Has anyone of your immediate family developed heart disease before the age of 60?
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Yes
No
Do any diseases run in your family?
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Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
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Yes
No
if yes please list:
Are you a current cigarette/cigar smoker?
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Yes
No
Your current diet could be best characterized as:
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Low-Fat
Low-Carb
Keto
Pescatarian
Vegetarian/Vegan
No special diet
Other
Please rate your readiness for change.
*
1
2
3
4
5
6
7
8
9
10
What following goals does best fit in with your goals?
*
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
Which type of coaching are you interested in?
*
Virtual Group or Personal Training
In Person Group Training
In Person Personal Training
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?
*
Please rate your motivational level to do what it takes for reach your goal.
*
1
2
3
4
5
6
7
8
9
10
Are you currently excersising regulary (at least 3x per week)?
*
Yes
No
Have you trained with a personal trainer before?
*
Yes
No
If yes what kind of training did you do:
At what times during the day would you prefer to train?
*
Morning
Mid-Day
Afternoon
Evening
How often do you want to do Personal Training a week?
*
Please Select
2 Sessions
3 Sessions
Please Choose
What are your expectations of me as your Personal Trainer?
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How did you hear about our services?
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Instagram
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