Full Name
*
First Name
Last Name
Gender
Male
Female
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
Ft
Weight
LBS
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 B3 Therapy LLC
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 $15 per day into working with myself over the next 90 days?
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
Please enter your email below
example@example.com
I AGREE TO THE ABOVE TERMS & CONDITIONS!
*
Yes
No
Signature
Submit
Submit
Should be Empty: