Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Male
Female
Prefer not to say
Age
years
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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2
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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2012
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2010
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1927
1926
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1923
1922
1921
1920
Year
Have you had a Personal Trainer before?
Yes
No
What is your current training routine like?
Eg, How many times are you training a week? How long are you training for each session? What type of training are you doing?
At what time do you prefer training?
Early AM
Late AM
Early PM
Late PM
Which of the following goals best fit in with your personal goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
What is your current job?
Do you follow a regular working schedule, do you work days, afternoon or nights?
Current Barriers stopping you from exercising?
If you have any diagnosed health problems list the condition(s).
If you have any injuries, please list them.
Please rate your motivational level to do what it takes to reach your goal.
1
2
3
4
5
6
7
8
9
10
What are your expectations on me as your Personal Trainer?
Any other comments or questions...
Submit
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