Personal Training Consultation Questionnaire

The purpose of this form is to help me better understand what you need to take your health & fitness to the next level. Please answer honestly as I have zero judgment and am certified to deal with numerous physical issues. Your answers will be confidential.
Name*

First NameLast Name
What is your current or former occupation?
What’s your normal daily activity level?*

None. Mostly sedentaryModerate. Light activity such as walkingHigh. Very active
Please list the physical activities that you participate in (gym, sports, garden, et cetera).*
Do you have

DiabetesHypoglycemia (low blood sugar)Asthma or pulmonary issueHypertension (high blood pressure)Hypotension (low blood pressure)Autoimmune issue
If you have any additional diagnosed or suspected health issues, please list the condition(s).
If you are on any medications, please list them.
What additional therapies are you using for the given health issue(s)?
If you have any current or lingering injuries, please list them.
What additional therapies are you using to treat the given injury?
Please list any other health conditions you have which could affect exercise or require movement modifications:
Are you a current tobacco user or vaper?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special dietOther
Please rate your readiness for change.

Let’s start yesterday!Will be ready very soonUnsure. Still gathering information
What following goals does best fit in with your goals?

Improve healthImprove enduranceIncrease strengthIncrease muscle massLook betterFat loss / lose weightRecover from an injury or surgeryPrepare for surgeryPrevent diseasePrevent injuryImprove balanceImprove quality of lifeOther:
What is your goal(s) with your training?
Why? How would this improve your life?

Timeline for achieving your goal.

	2 Months	4 Months	6 Months	1 Year	2 Years	Unsure
.

How often are you willing and able to train each week at least 30 minutes, including on your own?

1 time each week2 times3 times4 time5 times6 times7 times
Are you currently exercising regulary (at least 3x per week)?

YesNo
Have you worked with a personal trainer before?

YesNo
What type of training did you do?
Did you enjoy the training? What would have made it more effective?
At what times during the day would you prefer to train?

Early MorningMid-MorningLunchEarly AfternoonEveningWeekend
How often are you thinking you want to do Personal Training a week?
What are your expectations in your Personal Trainer?
ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE STATEMENT.*

YesNo
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

The purpose of this form is to help me better understand what you need to take your health & fitness to the next level. Please answer honestly as I have zero judgment and am certified to deal with numerous physical issues. Your answers will be confidential.