Individualized Personal Training Application

Personal Training Application

SHIFT Performance, 3851 N Lincoln Ave, Chicago, IL 60613
I am applying for:*

1:1 Personal TrainingSemi-Private (2-3 People)Online Programing
Full Name

First NameLast Name
Email
example@example.com
Gender

MaleFemalePrefer not to Identify
Date of Birth

MonthDayYear
Age
years
Height
Weight
lbs.
Part 2. Lifestyle Information
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?
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
Part 3. Medical and Health Information
If you have any diagnosed health problems list the condition(s).
If you have any injuries, please list them.
Are you experiencing any stresses or motivational problems?

YesNo
Part 4. Goals
Most important Goal?

Improved healthImproved enduranceIncreased strengthWeight Loss

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

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

MorningMid-DayAfternoonEveningOther
How often do you want to do Personalized Training a week?
Please Choose
Please Read The Following Terms and Conditions
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.
YesNo
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Personal Training Application