Personal Training Application

Part 1. Basic information
Personal Training Consultation Questionnaire
Full Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Age
years
Height
cm
Weight
KG
Part 2. Lifestyle Information
What do you do for a living?
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?
RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
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.
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?
YesNo
YesNo
if yes please list:
YesNo
low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Part 4. Goals
12345678910
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?
Why?
How often are you willing to train a week to reach your goal?
12345678910
YesNo
YesNo
If yes what kind of training did you do:
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
Should be Empty:

Part 1. Basic information