Personal Training Application Form

Part 1. Basic information
Personal Training Consultation Questionnaire
Full Name

First NameLast Name
Email
example@example.com
Gender
Date of Birth

MonthDayYear
Age
years
Height
cm
Weight
KG
Part 2. Lifestyle Information
What do you do for a living?
Whats the activity level at your job?
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?
Please list the physical activities that you participate in outside of the gym and outside of work.:
Part 3. Medical and health information
Are you currently pregnant?
If you have any diagnosed health problems list the condition(s).
Have you given birth in the past 12 months?
If "yes" please give a brief overview of your birth and recovery.
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?
Has anyone of your immediate family developed heart disease before the age of 60?
Do any diseases run in your family?
Do you suffer from diabetes, asthma, high or low blood pressure?
if yes please list:
Are you a current cigarette smoker?
Your current diet could be best characterized as:
Part 4. Goals
Please rate your readiness for change.
What following goals does best fit in with your goals?
What is your goal with your training?
Why?

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?
Please rate your motivational level to do what it takes for reach your goal.
Are you currently excersising regulary (at least 3x per week)?
Have you trained with a personal trainer before?
If yes what kind of training did you do:
What hurdles do you predict you may overcome to achieve your goals? eg childcare, shift pattern.
At what times during the day would you prefer to train?
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
Please Read The Following Terms and Conditions.
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.
Signature
I AGREE TO THE ABOVE TERMS & CONDITIONS!
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Please Read The Following Terms and Conditions.