Personal Training Consultation Questionnaire

Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Phone Number

Area CodePhone Number
Email
example@example.com
Age
years
Height
cm
Weight
KG
Do you know your body fat %?
%
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?

RarelyA few times a yearA few times a monthWeekly
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).
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
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
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

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.

12345678910
Are you currently excercising 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:
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
Additional App Product Options

App Program Support ($212/month)App Full Service ($400/month)
- App Program Support: Your personalised program, clean, clear, crisp!
- App Full Service: Full access to the app; habit tracking, personalised programming & nutrition support.
1) F2F SESSION 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) F2F LATE ARRIVALS
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) APP DEACTIVATION
App use is billed monthly and any cancellation must be made before the next billing cycle goes through. Once new month payment has gone through there are no refunds. Notification must be given to Keren prior to the new monthly bill cycle.
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.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Should be Empty: