Consultation Request Form

What services are you interested in? You can select multiple.

ProgrammingCoachingPersonal TrainingConsultation to learn about the above services to see if they will help me reach my goalsGym Orientation (offered by the gym at sign up)

What are your goals?

Increase StrengthIncrease FitnessIncrease Muscle MassDecrease Body Fat/WeightTone/Recomposition BodyImprove Health
Why is this important to you?
Be as detailed as possible

How many workouts do you do each week?

None1-22-33-56+
What is your current exercise routine or what exercise have you done in the past.

Average daily steps.
If you use a tracker look at your average from the past 2 weeks

Have you worked with a personal trainer before? What did you like, what didn't you like and did you get the desired results you were after?

If you have trained in the past and stopped, what was the reason?
This questions is designed to identify any potential roadblocks so be as honest as possible

What do you find most challenging when it comes to sticking with an exercise program?

Are you willing to make changes to your current diet, habits and lifestyle to get you to where you want to be?

Please describe what an average day of eating looks like for you?
Be as honest as possible as this will allow as to see areas in which we can focus on

Please describe your relationship with alcohol and list how many standard drinks you have each week.

Occupation
How many hours do you work each week?
Daily activity level (excluding purposeful exercise)

VERY Light - sitting most of the dayLIGHT - sitting, standing, light activityMODERATE - continuous moderate activity all dayHEAVY - continuous heavy/strenuous activity all day

How many hours of sleep do you get each night and what time do you go to bed?
Please add any extra information regarding your sleep.
Do to stay up late, do you wake up lots, do the kids wake you up?

How stressed do you feel on average?
If you are really stressed let me know about what's going on.

Think about a time in your life when you felt your best. What are 3 habits you had then that you don't have now?

How will you know if you have been successful as part of this coaching plan?
This question is designed to help me understand what success means to YOU and to dig a little deeper on your expectations.

Acknowledgment

I recognise that my trainer is unable to provide me with medical advice and that this information is only used as a guidline to the limitations of my exercise ability. I understand that answering "yes" to any of the above health screen questions will require me to provide a medical clearance before commencing any physical actiyity/exercise.

I have answered all questions to the best of my ability and will not hold Empower & Reform with Maggie or my trainer liable for any injuries or conditions that may occur as a result of my training.
Signature*

Powered by Jotform SignClear

Per Exercise Medical