Personal Training Intake Questionnaire

Personal Training Intake Questionnaire
Full Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age
years
Height
ft/in
Approximate Weight
lb
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 have any injuries, please list them.
Are you a current smoker?

YesNo
Your current diet could be best characterized as:*

Low-fatLow-carbHigh-proteinVegetarian/VeganUnhealthy 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?
What is your motivation for change?

TImeline for achieving your goal.*

	8 WKS	12 WKS	16 WKS	24 WKS	36 WKS	+1 YEAR
NOW

How often do you want to do Personal Training per week?*
Please Choose
How often are you willing to train on your own per week to reach your goal?*
Are you currently excersising regulary (at least 3x per week)?*

YesNo
What kind of training style do you participate in?
What kind of at-home modalities do you own? (Include type, weight and count)
ex. Dumbbells / 10 lbs / 1 pair
Do you have access to a gym?
Please explain if it is a Clubhouse Gym, At-home Gym or Membership Gym
Have you trained with a personal trainer before?*

YesNo
At what times during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
Please pick an available date/time for your Full Body Assessment below: *
Please include secondary date and time:
Should be Empty: