Consultation Questionnaire

Full Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Gender

Date of Birth

MonthDayYear

Age

years

Height

cm

Weight

KG

What do you do for a living?

Whats the activity level at your job?

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

Do any diseases run in your family?

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:

Please rate your readiness for change.

What following goals does best fit in with your goals?

TImeline for achieving your goal.

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

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.

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

Have you trained with a personal trainer before?

If yes what kind of training did you do:

How often do you want to do Personal Training a week?

Please Choose

Please Upload Your Current Picture

Browse Files

Front view

Browse Files

Rear view

1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) DURATION of Each session shall be 1 hour in length.

3.) Results are completely based on your sole performance and adherence to the program provided by the trainer. The trainer is not responsible for any injury or anything that causes you not to achieve your goal during the term of the program or personal training sessions.

ALL THE INFORMATION I HAVE GIVEN IS CORRECT.

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.

I AGREE TO THE ABOVE TERMS & CONDITIONS!