Readiness To Change Consultation Questionnaire

Readiness to Change Consultation Questionnaire

BEST DAY EVER PERSONAL TRAINING
This is a fill in the blanks field. Please add appropriate blank fields and text.
Full Name*

First NameLast Name
Gender

MaleFemale
Email*
Phone Number*
Date of Birth*

MonthDayYear
Age*
Height*
Weight*
What do you do for a living?
What's 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?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
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?

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

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
Please list:*
Your current diet could be best characterized as:

low-fatlow-carbhigh-protein/ketoVegetarian/VeganNo special 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?
Why?

TImeline for achieving your goal.

	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.

12345678910
Are you currently exercising regularly (at least 3x per week)?

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

TreadmillEllipticalBikeRowerDumbells/WeightsOther
What exercise do you enjoy doing the most and the least?*
Have you trained with a personal trainer before?

YesNo
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?

MorningMid-DayAfternoonEvening
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!*

YesNo
Should be Empty:

Readiness to Change Consultation Questionnaire