PT PACK
PERSONAL TRAINING CONSULTATION FORM
Name
First name
Last Name
Age
Years
Height
Cm
Weight
KG
What is your aims/goals with training?:
Why?:
What following goals best describe your goals:
Improved mobility
Improve Cardiovascular fitness
Diet & nutritional advice
Sport specific training
Fat loss
Improved strength
Rehabilitate an injury
Increased muscle mass
Start an exercise programme
design a more advanced programme
What do you do for a living?:
What’s the activity level of your job?
None (seated)
Moderate activity (light activity, standing, walking)
High (heavy labour)
Other (all of the above)
Do you follow a fixed working schedule? Do you work days, evening, nights?:
Please list the physical activities that you participate in outside of gym & work:
How would you rate your sleep pattern?
Poor
Average
Good
How many hours of sleep do you get per night?:
Hours
Are you experiencing and stresses or motivational problems?:
If yes please detail
What is your daily average step count?:
Please see smart device or health app
Do you currently smoke?
Yes
No
What would you best describe your current diet as:
Terrible
Poor
Average
Good
Perfect
How often are you currently involved in physical activity/training per week?:
None
1-3 days
3-5 days
5-7 days
How long have you been exercising for?
1 month or less
1 - 3 months
3 - 6 months
6months +
How often are you willing to train to reach your goal?
Days per week
Do you have any particular likes/dislikes when training?
On a scale of 1-10 how ready are you to make changes to reach your goal?:
1 being the lowest & 10 being the highest
At what time of the day do you prefer to train:
Morning
Mid day
Afternoon
Evenings
Other (mixture)
HEALTH HISTORY & PAR Q FORM
If you mark any of these statements in this section, consult your GP/ Health care provider before engaging in exercise. You will have to obtain written medical clearance from your GP.
HISTORY - you’ve had:
A heart attack
Heart surgery
Pacemaker/ implantable cardiac defibrillator
Heart problems
breathing problems
SYMPTOMS - you experience:
Chest discomfort with exertion
Unreasonable breathlessness
Dizziness, fainting or blackouts
OTHER HEALTH ISSUES:
You have diabetes
You have asthma
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You have concerns about the safety of exercise
I have read, understood & completed this questionnaire to the best of my knowledge. Any questions I had were answered to my full honesty and satisfaction. I understand that all the information given will be kept private & confidential.
I agree and confirm the following above.
Want book in for a call & a free consultation?
Please specificy what day/times are good for you and pop your number in the box above.
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