Rose Ramirez (FitMom) Personal Training Questionnaire

Do you smoke?

YesNo

If yes, how many per day?

Do you drink alchohol?

YesNo

If yes, how many per week?

How many hours do you regularly sleep at night?

What's the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)

How often do you take part in physical exercise?

If your participation is lower than you would like it to be, what are the reasons?

Lack of interestIllenss/InjuryLack of timeOther

Based on your commitment, how often would you like to see a personal trainer to help you achieve your goals?

What are the best days during the week for you to commit to your exercise program?

What are the best times for you to exercise?

MorningAfternoonEvening

Realistically, how many times per week do you expect to exercise and for how long each session?

Please list anything else that you may feel is a concern or information that has not been disclosed that may be pertinent to being physically active or working with a personal trainer.

I understand that it is my responsibility to keep track of all my training session appointments. In the event that I must cancel an appointment, I will give 24 hours' notice. If I do not give 24 hours' notice, my subjected to a session charge and that session may be forfeited.

Yes, I understand and agreeNo, I don't agree

Signature

Print Name

Date

1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) 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 TERMS & CONDITIONS!

YesNo

START HERE >> Rose Ramirez (FitMom) Personal Training Questionnaire

CLIENT INFORMATION

CURRENT FITNESS LEVEL & GOALS

YOUR HEALTH

LIFESTYLE

DEVELOPING YOUR FITNESS PROGRAM

CANCELLATION POLICY

CLIENT SIGNATURE