Solid State Mind and Body Inquiry Questionnaire

Solid State MB Inquiry Questionnaire
Full Name*

First NameLast Name
Gender*

MaleFemale
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Media Profile (ex: Instagram, Linkedin)
Date of Birth

MonthDayYear
Age
years
Height
cm
Weight
Pounds
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 work schedule? If so do you work days, afternoon or nights?
How often do you travel?

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:
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?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
Please list:
Your current diet could be best characterized as:

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Please rate your readiness for change.

12345678910
Which of the following best describes your fitness goals? (Check all that apply)

Weight loss / Fat lossMuscle building / Strength gainImprove endurance / Cardiovascular healthIncrease flexibility / MobilitySports performance enhancementInjury recovery / Pain managementGeneral health and well-beingOther
Why?
Do you have a specific timeline or event for achieving your fitness goals? If so, please describe your timeframe and any upcoming milestones (e.g., wedding, race, vacation, competition, etc.).
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.

12345678910
How often do you currently exercise?

NoYes, 1-2 day(s) per weekYes, 3-4 days per weekYes, 5+ days per week
Have you trained with a personal trainer before?

YesNo
What kind of training did you do?
What are your available times to train? (Example: Mondays 5p-6p, Tuesdays 7p-8p)
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
Should be Empty:

Solid State MB Inquiry Questionnaire