Personal Training Consultation Questionnaire
*Thank you for your interest in customized online personal training! Please fill out the following information to help us tailor a training program specifically for you.*
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Age
*
years
Height
*
cm
Weight
*
KG
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?
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?
Yes
No
Has anyone of your immediate family developed heart disease before the age of 60?
Yes
No
Do any diseases run in your family?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
*
Yes
No
Please list:
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
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
What following goals does best fit in with your goals?
*
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
What is your goal with your training?
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
Have you trained with a personal trainer before?
*
Yes
No
At what times during the day would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
What are your expectations on me as your Personal Trainer?
Submit
Should be Empty: