Get Started with Personal Training

1
Name* This field is required.
First Name
Last Name
2
Birthday* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Male
Female
Other/Prefer Not to Say
4
Location* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Liberia
Libya
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Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
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Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Samoa
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Senegal
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eSwatini
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Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Email
example@example.com
6
Mobile Number
Area Code
Phone Number
7
How would you like me to contact you?* This field is required.
Call
Text
E-Mail
8
Height in Inches* This field is required.
9
Weight in Pounds* This field is required.
10
Occupation* This field is required.(also let me know if you are a student!)
11
Are there specific days and times you prefer for your workout sessions?* This field is required.e.g., Monday and Wednesday at 6:30AM, Weekdays any time after 5PM
12
Does your occupation require any of the following?* This field is required.Select all that apply.
Extended periods of sitting
Wear uncomfortable shoes or shoes with a heel
Repetitive movements
None of these
13
Emergency Contact Name* This field is required.
First Name
Last Name
14
Emergency Contact Relationship* This field is required.
15
Emergency Contact Number* This field is required.
Area Code
Phone Number
16
Do you have any history with weightlifting?* This field is required.
Dumbbells and/or Kettlebells
Barbells
Machines/Cables
Nope, but I'm excited to learn!
17
What exercise activities do you CURRENTLY take part in and how often?* This field is required.e.g., running, weightlifting, yoga, group exercise, etc. & frequency
18
How many days per week do you get at least 45 minutes of moderate-intensity exercise?i.e., raised heart rate, faster breathing
Please Select
Please Select
0
1
2
3
4
5
6
7
19
Do you partake in any recreational physical activities? If yes, which one(s)?* This field is required.e.g., golf, skiing, hiking, kayaking, etc.
20
Do you have any additional hobbies?* This field is required.e.g., gardening, fishing, reading, cooking, etc.
21
On a scale of 1 to 5, how important are the following fitness goals to you?* This field is required.
1: Not at All
2: Somewhat Important
3: Important
4: Very Important
5: Top Priority
Weight Loss
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Muscle Gain
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Row 1, Column 2
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Health Improvement
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Sports Performance
Row 3, Column 0
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Weight Loss
Muscle Gain
Health Improvement
Sports Performance
1: Not at All
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2: Somewhat Important
Row 0, Column 1
3: Important
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4: Very Important
Row 0, Column 3
5: Top Priority
Row 0, Column 4
1: Not at All
Row 1, Column 0
2: Somewhat Important
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3: Important
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4: Very Important
Row 1, Column 3
5: Top Priority
Row 1, Column 4
1: Not at All
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2: Somewhat Important
Row 2, Column 1
3: Important
Row 2, Column 2
4: Very Important
Row 2, Column 3
5: Top Priority
Row 2, Column 4
1: Not at All
Row 3, Column 0
2: Somewhat Important
Row 3, Column 1
3: Important
Row 3, Column 2
4: Very Important
Row 3, Column 3
5: Top Priority
Row 3, Column 4
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On a scale of 1 to 5, do you consider your overall diet to be healthy?* This field is required.
1: Not at All Healthy
2
3
4
5: Extremely Healthy
23
Are you currently following any kind of diet? If so, what diet and for what reason(s)?* This field is required.e.g., Vegan, Paleo, Mediterranean, Ketogenic, etc. & why?
24
Are you currently taking any nutritional supplements? If so, what are they?* This field is required.e.g., vitamin D, iron, creatine, magnesium
25
On a scale of 1 to 5, how effectively are you able to control your temptations for junk food?* This field is required.
1: Not at All Effectively
2
3
4
5: Extremely Effectively
26
How many alcoholic drinks do you consume per week?* This field is required.
None
1-2
3-5
6-9
10 or more
27
How many caffeinated beverages do you consume per week?* This field is required.e.g., coffee, tea, energy drinks, soda, pre-workout
None
1-2
3-5
6-9
10 or more
28
Do you feel like you get enough sleep and wake up feeling rested each day?
YESNO
29
Do you smoke tobacco or use a vaporizer alternative?* This field is required.
YESNO
30
Do you use a fitness, activity or step tracker? If so, which one?* This field is required.e.g., FitBit, Apple Watch, Garmin
31
Is there anything else you'd like me to know before we get started?This can be personal, medical, or anything else you think I might need to know.
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