Kilo Nellz Athletics

KILO NELLZ ATHLETICS QUESTIONNAIRE

JOIN THE TEAM!!
Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age
years
Height
ft
Weight
If unknown that's okay
Phone Number

Area CodePhone Number
Email
How do you prefer to be contacted?
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 are on any medications, please list them.
If you have any injuries, please list them.
Are you experiencing any stresses or motivational problems?

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

YesNo
if yes please list:
Are you a current cigarette smoker?

YesNo
Please rate your readiness for change.

12345678910
What following goals does best fit in with your goals?

Improved HealthTone UpIncreased StrengthIncreased Muscle MassFat LossWeight GainBuild Gym Confidence
What is your goal with your training?
Are you currently excersising?

YesNo
Have you trained with a personal trainer before?

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

MorningMid-DayAfternoonEvening
What are your expectations on me as your Personal Trainer?
Phone Number

Area CodePhone Number
Should be Empty:

KILO NELLZ ATHLETICS QUESTIONNAIRE