Personal Training Application
Name
*
First Name
Last Name
Email
*
Example@example.com
Date of Birth
-
Month
-
Day
Year
Gender
Male
Female
Age
Years
Height
Feet and inches
Weight
Lbs
How would you prefer to work with your trainer?
Please Select
In-Person Training
Online Coaching
Have you trained with a personal trainer before?
Yes
No
Which of the following best describes your goals?
Fat loss
Muscle gain
Lifestyle and habit building
Overall health
How committed are you to making a change and reaching your goals
Not ready
1
2
3
4
Fully committed
5
1 is Not ready , 5 is Fully committed
What has been the biggest limiting factor keeping you from achieving these goals in the past?
What is the activity level at your job?
None (seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you work days or nights?
List any physical activities that you participate in outside of work.
List any diagnosed health problems or injuries.
If you are on any medications, please list them.
Are you experiencing any significant stress?
Yes
No
Are you a current cigarette smoker?
Yes
No
Your current diet could be best characterized as:
Low-fat
Low-carb
High-protein
Vegetarian/Vegan
No special diet
How many days a week are you currently exercising?
How many days a week can you commit to training?
Additional comments or questions.
Submit
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