Personal Training Program Questionnaire

Personal Training Program Questionnaire
Full Name

First NameLast Name
Contact Information

EmailTelephone Number
Are you ok if I text you in regards to this form?

Yes, totally!No, email me instead
Gender

MaleFemaleOther
Date of Birth

MonthDayYear
Age
years
Height
cm
Weight
LBS
What do you do for a living?
What is your equestrian sport?

DressagePoloHunter jumperEquitationShow jumpingOther
What does your current fitness regime look like?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
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
Do any diseases run in your family?

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

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
What is your goal with your training?
Why?
Have you trained with a personal trainer before?

YesNo
Can you tell me more about that experience?*
How often do you want to exercise per week?
Please Choose
What are your expectations on me as your Personal Trainer?
Anything else I need to know?
1.) 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: