Personal Trainer Client Intake and Liability Form

Intro to Personal Training Questionnaire

1 Free Session with Ariel Humnphrey
Full Name*

First Name Last Name
Height*
Inches
Weight*
lb
Phone Number*

Area Code Phone Number
Email*

Confirmation Email example@example.com
What is the best way to contact you?*

Phone callEmailText
Goals
Which of the following goals best fit in with your goals for your training (select all that apply)?*

Appearance/AestheticsCardiovascular EnduranceFlexibilityHealth (General)Muscular DefinitionMuscular SizeMuscular Strength/PowerSelf-esteem/ConfidenceSpeedSports PerformanceStress ReductionWeight LossPosture
What are the top three goals you want to accomplish, in order of importance?*
Explain why these three goals are most important to you.*

Please rate your motivational level to do what it takes to reach your goal.*

	1	2	3	4	5	6	7	8	9	10

1 is I have no motivation to change my life., 10 is Im ready to make any lifestyle changes to reach my goals!

What possible personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?*

Lack of motivationTimeSelf ConsciousLack of equipmentLack of ResultsHitting A PlateauMoneyNot knowing where/how to begin
Have you had any recent weight gain or loss?*

YesNo
If yes, please explain:
Do you currently exercise on a regular basis?*

YesNo
If yes, how many days a week?
How long is each session in minutes?
Have you trained with a personal trainer before?*

YesNo
If yes, was your previous experience negative or positive? Why?

Please rate how you feel your current nutritional habits are*

	1	2	3	4	5	6	7	8	9	10

1 is I don’t worry about what I eat, I just eat whatever, wherever., 10 is I am very conscious of my food choices and eat whole foods fruits, and vegetables, and limit my processed food intake.

Should be Empty:

Intro to Personal Training Questionnaire

Goals