Personal Training Consultation Questionnaire

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(Preliminary Questionnaire)
Name*

First NameLast Name
Email*
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Height
Weight
What time of the day do you start work?

MorningAfternoonEveningI'm retired
What's the activity level at your job?

none (seated only)Moderate (light activity such as walking)High (heavy labor, very active)
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
Do you have any injuries?

YesNo
Please list your injuries:
Do you have any diagnosed health issues?

YesNo
Please list your health issues:
Are you a current cigarette smoker?

YesNo
Do you vape?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinBalancedVegetarian/VeganNo special dietOther
Which of the following are you interested in?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
Are you currently excersising regulary (at least 3x per week)?

YesNo
How many days per week do you exercise?
Have you trained with a personal trainer before?

YesNo
What kind of training did you do?
How many days per week would you like to work with a trainer?
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
Anything else you'd like us to know?
Should be Empty:

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