Personal Training Consultation Questionnaire

Full Name

First NameLast Name

Email

example@example.com

Gender

Date of Birth

MonthDayYear

Age

years

Height

IN

Weight

LBS

What form of training are you interested in?

What do you do for a living?

Whats the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

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?

Has anyone in your immediate family developed heart disease before the age of 60?

Do any diseases run in your family?

if yes please list:

Do you suffer from diabetes, asthma, high or low blood pressure?

if yes please list:

Are you a current cigarette smoker?

Your current diet could be best characterized as:

Which following goals best fit in with your goals?

Why?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

Are you currently excersising regulary (at least 3x per week)?

How often are you willing to train a week to reach your goal?

At what times during the day would you prefer to train?

Have you trained with a personal trainer before?

If yes what kind of training did you do:

Please rate your readiness for change.

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.

Date