MUSE Maintenance Consultation Questionnaire
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Male
Female
Age
years
Height
Weight
Occupation
What is your daily activity level?
None (seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
Do you suffer from any of the following conditions?
Asthma
High Blood Pressure
Low Blood Pressure
N/A
Please specify any other conditions that wasn't listed above.
List any injuries you may have.
Are currently participating in any therapy for the previous listed injury?
Are you experiencing any stresses or motivational problems?
Yes
No
Please share what may possibly be hindering you:
Are you a current smoker? (cigarette, recreational, etc.)
Yes
No
List any additional physical activities that you participate in.
Your current diet could be best characterized as:
Low-Fat
Low-Carb
High Protein
Vegetarian/Vegan
Gluten Free
No Special Diet
Rate your readiness for change. BE HONEST! Factor in your willingness to put forth maximum effort. NO EXCUSE MENTALITY!
1
2
3
4
5
6
7
8
9
10
Which of the following aligns with your fitness goals?
Improved overall health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
What are your specific target areas would you like to focus on?
Lower Body (Glutes, Quads, Hamstrings, Calves, etc.)
Upper Body (Chest, Shoulders, Triceps, Biceps)
Back
Midsection (Core, Abs)
Cardiovascular
What is your current fitness level?
Extreme Beginner (HELP ME PUHLEASE!!)
Aspiring Fitness Influencer (does everything a gym girly does except workout lol)
Intermediate (slightly knowledgeable about the gym & growing those glutes)
Pro Fitness (Here for accountability and growth)
Timeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
How often are you willing to train a week to reach your goal?
Are you currently excersising regulary (at least 3x per week)?
Yes
No
If not, what is holding you back from dedicating 3 days out the week?
Are you looking to train IN PERSON or ONLINE ?
Have you trained with a personal trainer before?
Yes
No
What time would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
What are your expectations of me as your Personal Trainer?
Tentative Start Date
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