PT Assessment Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Age: 35 * Height & Weight: 5'7" & 150 lbs *

5

Do you have a specific goal in mind?* This field is required.

6

Why is this goal so important to you?* This field is required.

7

What are your current activity levels?* This field is required.

Low

Medium

High

8

Are you currently following a strength and conditioning plan?* This field is required.

YESNO

9

Do you barbell Squat, barbell Bench press and/or barbell Deadlift?* This field is required.

No, not regularly

Never have

All the time

One or two of them but not all

10

Are you currently following a nutrition plan?* This field is required.

YESNO

11

Briefly Provide an example food log of your best days and your worst days:* This field is required.(Think everything you eat/drink from morning to night)

12

Do you have any recurring injuries, pain or discomforts we should know about?* This field is required.

13

Are you taking any medications or supplements we should know about?* This field is required.

14

What is your access to equipment?* This field is required.

Little to nothing

Dumbbells and a bench but no barbells

Squat rack and barbells

Full gym access

15

How many days a week can you consistently workout?* This field is required.

2-3

3-4

4-5

5+

16

In terms of reaching your goals, what do you think is your biggest obstacle?* This field is required.

17

Set a timer for 60s and see how many squats you can perform and record below

18

Set a timer for 60s and see how many pushups you can perform and record below

19

Set a timer for 60s and see how many sit-ups you can perform and record below

20

Anything else you'd like your coaches to know?(Optional)