Pre Program Questionnaire
Once you fill out this form I will book in a call with you via your mobile number to discuss your personal goals, how I can assist you in achieving those goals & what my program offers.
Full Name
First Name
Last Name
Email
example@example.com
Birth Date
-
Month
-
Day
Year
Date
Age
years
Height
cm
Weight
kg
Phone Number
Email
Please state if you have current/previous health issues.
Please state whether you take any medication or are on birth control.
Please state what you do for a living.
What's the activity level at your job?
None (minimal movement eg seated)
Moderate (light activity eg walking)
High (Heavy labor, very active)
Health & Lifestyle
Yes
No
Have you had any surgery since one year?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Do you have any experience training at a gym prior?
Do you feel pain while doing sports/exercise?
Are you anxious when it comes to training in a gym?
Are you confident with training in a gym?
At which frequency you eat at night?
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
At which frequency you eat breakfast?
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
What is your rate for your nutrition?
Poor
0
1
2
3
4
Excellent
5
0 is Poor, 5 is Excellent
Please select the reasons you eat (besides hunger).
Stress
Depression
Boredom
Happiness
Habit
Annoyance
Do you have any dietary requirements? E.g Allergies or food preferences
How many days are you wanting to workout per week?
4 days
5 days
6 days
How many year experience do you having training? Are you into any other sport besides the gym?
Best days for rest days? (At least 2)
What are your goals for training?
Muscle development
Mental health reasons
Weight loss
Training for an event/specific sports
Other
Release and Acknowledgement
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential. The fitness center has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge the fitness center trainers, administration and workers from any disclosure of my personal information in this Fitness Client Intake Form. If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the fitness center authorities immediately.
Date
-
Month
-
Day
Year
Date
Client Signature
Submit
Should be Empty: