Personal Training Information

Personal Information:
Email*
example@example.com
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Age*
Years
Height*
FT and IN
Weight*
KG or LB
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.:*
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
Has anyone of your immediate family developed heart disease before the age of 60?*

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 currently taking any supplements if yes please list below.*

YesNo
Please list*
Food allergies: If yes please list below.*

YesNo
Please list*
Are you a current cigarette smoker?*

YesNo
Are you a current alcohol consumer?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
What following goals does best fit in with your goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?*
Please rate your motivational level to do what it takes for reach your goal.*

12345678910
Are you currently excersising regulary (at least 3x per week)?*

YesNo
Have you ever trained with a trainer before?*

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

MorningMid-DayAfternoonEvening
How many days do you want to Workout a week?*
Please Choose
What are your expectations on me as your Trainer?*
Picture of the Front, Back, and Both sides of your body.*

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