Personal Training Application Form

Part 1. Basic information
Personal Training Consultation Questionnaire
Full Name

First NameLast Name
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?
Part 3. Medical and health information
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
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 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
What following goals does best fit in with your goals?
Are you currently excersising regulary (at least 3x per week)?
Have you trained with a personal trainer before?
Email
example@example.com
Should be Empty: