Shaping Fitness Consultation Questionnaire
Part 1. Basic information
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your preferred form of contact?
Email
Text
Gender
Male
Female
Are you currently pregnant?
Yes
No
Have you given birth within the past 6 weeks?
Yes
No
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
years
Height
in
Weight
LBS
How did you hear about us?
Please Select
instagram
Google
Referral
Business Card
other
Referral Name
Please list:
Part 2. Lifestyle Information
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 have a consistent work schedule?
Please Select
Yes
No
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly
Do you participate in activities outside of work?
Yes
No
Please list any physical activities that you participate in outside of the gym and work
How many meals a day do you eat?
Please Select
1-2
2-3
3-4
I eat inconsistently
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
Part 3. Medical and Health Information
Have you ever been diagnosed with any of the following? check all that apply:
High bloodpressure
Low bloodpressure
High cholesterol
Heart condition
Vertigo
Asthma
Arthritis
Have you been diagnosed with anything else that I should know about?
Yes
No
Please list:
Are you currently on any medications?
Yes
No
Please list them.
Do you have any pains or injuries I should know about?
Yes
No
Are you currently in physical therapy?
Yes
No
Please list your pain and injuries.
Are you experiencing any stresses or motivational problems?
Yes
No
Are you a current cigarette smoker?
Yes
No
Part 4. Goals
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? Check all that apply.
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
Have you tried to achieve these goals in the past?
Yes
No
Please explain how you went about it.
Is there a specific reasoning you want personal training?
Yes
No
Please explain:
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
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
What kind of training did you do?
Did you have a specific trainer in mind that you wanted to work with?
Yes
No
Please select the trainer.
Marisa
Kaylee
If everything you said above is true, please type your name here. Thank you for inquiring, we will reach out to you shortly!
Submit
Should be Empty: