Application and Free 30 minute Meeting Sign-Up
Dr. Zachary Ellis - Online Personal Training
Name
*
First Name
Last Name
Date of Birth:
*
Gender
*
Male
Female
Email
*
example@example.com
What can I do for you?
*
This program requires equipment (Barbells, dumbbells, resistance bands, medicine ball, etc.) . Do you have access to a gym?
*
Yes
No
How often are you currently exercising per week?
*
0-1
2-3
4-5
6+
How often would you like to exercise per week?
*
How important is your own health to you?
*
I am too busy to care for myself
I struggle to make time to care for myself
I balance my health with other obligations
I prioritize my health over other obligations
How will improving your health affect your life?
*
What is your occupation?
*
How physically demanding is your occupation?
*
None
Mild
Moderate
High
What is your weekly work schedule?
*
How active are you outside of work and the gym?
*
None
Mild
Moderate
High
Do you have any current or past injuries you are concerned about?
*
Pick your top 3 priorities
*
Strength/Explosiveness
Speed, Agility, Balance
Mobility, Motor Control
Injury Prevention (past injury concerns)
Time Management/Workout Efficiency
Workout Sustainability/Flexibility
Other
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What are your expectations on me as a personal trainer?
*
Why are you a good candidate for this program?
*
Physical Activity Readiness Questionnaire
Please answer the Questions below
Have you ever been advised by a doctor that you have a heart condition and should only do physical activity recommended by a doctor?
*
YES
NO
Do you ever feel pain in your chest when you perform physical activity?
*
YES
NO
Have you ever had chest pain when you are not doing physical activity?
*
YES
NO
Do you ever feel faint or have spells of dizziness?
*
YES
NO
Do you have bone or joint problems that could be made worse by exercise?
*
YES
NO
Have you ever been told that you have high blood pressure?
*
YES
NO
Are you currently taking any medication?
*
YES
NO
If the above answer is 'YES' then please describe below:
Are there any other reasons not mentioned why you should not exercise?
*
YES
NO
If the above answer is 'YES' then please describe below:
Type any Questions or Comments
Free 30 Minute Meeting (Google Meet)
*
Email drzacharyellis@gmail.com for additional scheduling times
Check your email for appointment confirmation!!!😄
Website
:Â
https://drzacharyellis.com
Program Details:
Click
Here
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