Full Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2026
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Year
Age
years
Height
cm
Weight
KG
What do you do for a living?
Whats the activity level at your job?
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?
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
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?
Are you experiencing any stresses or motivational problems?
Yes
No
Has anyone of your immediate family developed heart disease before the age of 60?
Yes
No
Do any diseases run in your family?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
if yes please list:
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
What following goals does best fit in with your goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
What is your goal with your training?
Why?
What are your expectations on me as your Personal Trainer?
If I gave you a plan to follow would you be able to spend 3 hours per week working on it to achieve the results you want
In 90 days time what would you need to achieve in order for you to label working with myself a success
What makes you think that you would be a good fit for the Pursuit Powerhouse training?
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.
1
2
3
4
5
6
7
8
9
10
Are you currently excersising regulary (at least 3x per week)?
Yes
No
Have you trained with a personal trainer before?
Yes
No
If yes what kind of training did you do:
Do you have the finances to invest $8-$10 (the average cost of take out coffee) per day into working with myself over several weeks?
Yes, I understand investing in myself is how I will achieve what I need
Maybe, I have the funds but I need some more info
No, I don't have the money to commit
Best email to contact you
example@example.com
I AGREE TO THE ABOVE TERMS & CONDITIONS!
*
Yes
No
Signature
Submit
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