Personal Training Consultation Form

1
Name* This field is required.
Preferred name/nickname
Last Name
2
Gender* This field is required.
Female
Male
Prefer not to say
Other
3
Date of Birth* This field is required.
Date
Year
Month
Day
4
Email Address* This field is required.
example@example.com
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Emergency Contact* This field is required.
Contact Name
Contact Number
7
Occupation* This field is required.
What is your occupation?
8
Have you or your direct family had any of the following:
Diabetes
Heart problems
High/low cholesterol
High/low blood pressure
Asthma
Arthritis
Chest pain
Osteoporosis
Epilepsy
Current pregnancy (women only)
None
Other
9
Do you smoke/vape?
YESNO
10
Do you currently take any medication?
YESNO
11
What medication are you taking?
If none, type "none" or "N/A"
12
Have you ever injured the following areas of your body:
Head
Neck
Torso
Shoulders
Arms
Hands/Wrists
Hips
Spine
Knees
Upper legs
Lower legs
Ankles/Feet
No injuries
Other
13
Description of injury/injuries if necessary:
Huge
Large
Normal
Small
Ok
Ok
14
Do you have any long term or short term goals?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
15
On a scale of 1-10, how would you rate your current motivation level to reach your goals?* This field is required.
16
Is there anything that would prevent you from reaching your goals?* This field is required.
17
On a scale of 1-10, rate your current nutrition & explain why you gave that rating* This field is required.
18
On a scale of 1-10, rate your current energy levels & explain why you gave that rating* This field is required.
19
On a scale of 1-10, rate your sleep & explain why you gave that rating* This field is required.
20
Did you exercise in the past? If so what type of training and how often?If you have not recently exercised regularly, skip this question.
21
How many days a week do you currently exercise?* This field is required.
0
1
2
3
4
5
6
7
22
If you exercise- on a scale of 1-10, rate the level of intensity/difficulty of your current exercisesIf you are not currently exercising, skip this question.
23
If you exercise, what do you like/dislike about your current routine?* This field is required.
24
On average, how long would you like to exercise for?* This field is required.
30 Minutes
45 Minutes
1 Hour
More than 1 hour
25
How many days per week would you like to exercise in total?* This field is required.
26
Would you like to train with a PT? If so, how many days?* This field is required.
27
What kind of training are you interested in doing?* This field is required.
Structured resistance training
Circuit training
Endurance training
Mixed training
Something else
28
Are you interested in working with me in a dietetics capacity?
YESNO
29
Do you know your current weight? (optional)
30
Do you know your height?
31
Has your medical practitioner ever told you that you have a heart condition, or have you ever suffered a stroke?
YESNO
32
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
YESNO
33
Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
YESNO
34
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
YESNO
35
If you have diabetes (type l or type ll) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
YESNO
36
Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
YESNO
37
Do you have any other conditions that may require special consideration for you to exercise?
YESNO
38
IF YOU ANSWERED YES to any of the 7 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise OR if you have already done so OR answered NO to the 7 questions, select the following:
I acknowledge that I am currently under the supervision of a medical practitioner who has approved my participation in an exercise program.
39
IF YOU ANSWERED 'NO' to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise. Select the following:
I meet the criteria to proceed.
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Informed Consent* This field is required.
I acknowledge that the information provided above regarding my health & personal information is, to the best of my knowledge, correct.
I will inform Kate Freeman immediately if there are any changes regarding my health status.
I understand that participating in physical activity & exercise can carry a risk, & I accept all responsibility of that risk.
I understand that due care will be undertaken by Kate Freeman at all times.
If/when taking on personal training I will endeavour to give Kate Freeman at least 24 hours notice of any cancellation/rescheduling of consultation/appointments (after which I will forfeit half of the session fee up until 2 hours or less before the session, in this case I will forfeit the entire fee.)
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Signature* This field is required.
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Yes, subscribe me to this newsletter.
43
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ORDER SUMMARY
Total costAUD
Tailored Calories & Maconutrient TargetsNot sure how many calories you should be eating in a day? Want tailored protein, fat and carbs numbers for each meal? Let me help calculate your unique targets to hit your goals.
$20.00AUDEdit
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Custom Meal PlanWant to take away all the guesswork and planning around meals? Let me create a 7 day meal plan unique to your goals.
$80.00AUDEdit
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Dietitian Initial ConsultaionWant to speak to an accredited practicing dietitian about your nutrition concerns? Book your initial consultation here!
$110.00AUDEdit
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Total cost $0.00AUD
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