Consultation Questionnaire

Full Name*

First NameLast NameSuffix
MaleFemaleOther
Phone:*
Best time to call: *
Email:*
Date of Birth*

MonthDayYear
Age*
Height*
Current Weight*
What do you do for a living?*
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?*
RarelyA few times a yearA few times a monthWeeklyOther
Please list the physical activities that you participate in outside of the gym and outside of work.:*
If you have any diagnosed health problems list the condition(s).*
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.*
What additional therapies are being undertaken for the given injury?
When was the last time you were genuinely happy? Why?*
YesNo
YesNo
YesNo
YesNo
if yes please list:
YesNo
Low-FatLow-CarbKetoPescatarianVegetarian/VeganNo special dietOther
12345678910
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
Virtual Group or Personal TrainingIn Person Group TrainingIn Person Personal Training
What is your goal with your training?*
Why?*

TImeline for achieving your goal.*

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