Personal Training Consultation Questionnaire

Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
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?
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?
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 excersising 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?
What Service Interests You?

1-1 In Person TrainingOnline CoachingHybrid
I understand that MEMC Fitness operates on a scheduled hourly appointment basis for private training sessions. Therefore, when canceling an appointment, I am required to provide MORE than 24-hour notice, for which no additional levy shall be incurred. However, if I cancel a session LESS than 24 hours before the scheduled time, I shall be charged in full for that training session. I understand that I’m entitled to a one-time cancellation fee waiver, whereby I can cancel a session in less than 24-hours, at no additional charge.

However, if the scheduled appointment is requested to be moved to a different time within that same week (if available), no additional charges will be added to my invoice for the missed session. Moreover, in the event of an emergency, I will be waived of the cost with no penalty.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Should be Empty: