Online Personal Training Consultation Questionnaire

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Age

Height

Weight

What do you do for a living?

Whats the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

If you have any injuries, please list them.

Are you experiencing any stresses or motivational problems?

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

Do any diseases run in your family?

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

Please list:

Are you a current cigarette smoker?

How often do you consume alcohol?

Your current diet could be best characterized as:

Please rate your readiness for change.

What following goals does best fit in with your goals?

What is your specific goal with your training?

Why?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR +
NOW

Please rate your motivational level to do what it takes for reach your goal.

Are you currently excersising regulary (at least 3x per week)?

Please list the physical activities that you participate in outside of the gym:

How often are you willing to exercise a week to reach your goals?

How much time a day can you spend exercising?

Where do you plan to perform your exercise? ( At home, gym, etc.)

Are you willing to meal prep to help achieve your goals?

What supplements are you currently taking?

Have you trained with a personal trainer before?

What kind of training did you do? Why did you stop?

What are your expectations on me as your Personal Trainer?

1.) You should consult with your physician before starting any physical activity program. Share this questionnaire and your training goals with your doctor.

2.) 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.

Signature

I AGREE TO THE ABOVE TERMS & CONDITIONS!