Personal Training Application Form

1
Full Name* This field is required.
First Name
Last Name
2
Gender
Male
Female
3
Date of Birth* This field is required.
Month
Day
Year
4
Age
years
5
Height
Feet
6
Weight
lbs
7
Email
example@example.com
8
Phone Number
Area Code
Phone Number
9
What do you do for a living?
10
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
11
Do you follow a regular working schedule, do you work days, afternoon or nights?
12
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly
13
Please list the physical activities that you participate in outside of the gym and outside of work.:
14
If you have any diagnosed health problems list the condition(s).
15
If you are on any medications, please list them.
16
What additional therapies are being undertaken for the given health problem(s)?
17
If you have any injuries, please list them.
18
What additional therapies are being undertaken for the given injury?
19
Are you experiencing any stresses or motivational problems?
Yes
No
20
Has anyone of your immediate family developed heart disease before the age of 60?
Yes
No
21
Do any diseases run in your family?
Yes
No
22
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
23
if yes please list:
24
Are you a current cigarette smoker?
Yes
No
25
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
26
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
27
What following goals does best fit in with your goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
28
What is your goal with your training?
29
Why?
30
TImeline for achieving your goal.
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
NOW
8 WKS
Row 0, Column 0
16 WKS
Row 0, Column 1
24 WKS
Row 0, Column 2
32 WKS
Row 0, Column 3
40 WKS
Row 0, Column 4
1 YEAR
Row 0, Column 5
31
How often are you willing to train a week to reach your goal?
32
Please rate your motivational level to do what it takes for reach your goal.
1
2
3
4
5
6
7
8
9
10
33
Are you currently excersising regulary (at least 3x per week)?
Yes
No
34
Have you trained with a personal trainer before?
Yes
No
35
If yes what kind of training did you do:
36
At what times during the day would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
37
How often do you want to do Personal Training a week?
1 Session
2 Sessions
3 Sessions
4 Sessions
5 Sessions
6 Sessions
7 Sessions
Please Choose
38
What are your expectations on me as your Personal Trainer?
39
I AGREE TO THE ABOVE TERMS & CONDITIONS!* This field is required.
Yes
No
40
1.) CANCELLATIONS Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client. 2.) LATE ARRIVALS Each in person session shall be 45min-1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client. 3.) 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.
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