Free Consultation & Assessment

Personal Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

FemaleMale
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred method of contact: (Select all that apply)

Phone callFacetimeTextEmail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lifestyle Info
How does your current diet look like?

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Do you smoke?

YesNo
Do you consume alcohol?

YesNo
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
Do you have any injuries? If yes, please list below.
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Training Preferences
How many days of the week do you want to workout?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
What kind of training are you looking for?

1-on-1 Private Personal TrainingOnline TrainingHybird (online & in-person)
Which of the following statements fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Consultation & Assessment
Are you interested in a free consultation to discuss your fitness goals further?

YesNo
Preferred Consultation Date and Time:(select all that apply)

WeekdaysWeekendsMorningsEveningsVirtually (FT/ZOOM)In-Person
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Should be Empty:

Personal Information

Lifestyle Info

Training Preferences

Consultation & Assessment