Readiness To Change Consultation Questionnaire

This is a fill in the blanks field. Please add appropriate blank fields and text.

Full Name

First NameLast Name

Gender

Email

Phone Number

Format: (000) 000-0000.

Date of Birth

MonthDayYear

Age

Height

Weight

What do you do for a living?

What's the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

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?

Please list:

Your current diet could be best characterized as:

Please rate your readiness for change.

What following goals does best fit in with your goals?

What is your goal with your training?

Why?

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 exercising regularly (at least 3x per week)?

Online Clients Only - What equipment do you have access to?

What exercise do you enjoy doing the most and the least?

Have you trained with a personal trainer before?

What kind of training did you do?

What did you like most and least about them?

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

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

Please Choose

What are your expectations on me as your Personal Trainer?

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!

Readiness to Change Consultation Questionnaire