Application and 30min Meeting

Application and Free 30 minute Meeting Sign-Up

Dr. Zachary Ellis - Online Personal Training
Name*

First NameLast Name
Date of Birth:*
Gender*

MaleFemale
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?*

YesNo
How often are you currently exercising per week?*

0-12-34-56+
How often would you like to exercise per week?*
How important is your own health to you?*

I am too busy to care for myselfI struggle to make time to care for myselfI balance my health with other obligationsI prioritize my health over other obligations
How will improving your health affect your life?*
What is your occupation?*
How physically demanding is your occupation?*

NoneMildModerateHigh
What is your weekly work schedule?*
How active are you outside of work and the gym?*

NoneMildModerateHigh
Do you have any current or past injuries you are concerned about?*
Pick your top 3 priorities*

Strength/ExplosivenessSpeed, Agility, BalanceMobility, Motor ControlInjury Prevention (past injury concerns)Time Management/Workout EfficiencyWorkout Sustainability/FlexibilityOther
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?*

YESNO
Do you ever feel pain in your chest when you perform physical activity?*

YESNO
Have you ever had chest pain when you are not doing physical activity?*

YESNO
Do you ever feel faint or have spells of dizziness?*

YESNO
Do you have bone or joint problems that could be made worse by exercise?*

YESNO
Have you ever been told that you have high blood pressure?*

YESNO
Are you currently taking any medication?*

YESNO
If the above answer is 'YES' then please describe below:
Are there any other reasons not mentioned why you should not exercise?*

YESNO
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: https://drzacharyellis.com

Program Details: Click Here
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Application and Free 30 minute Meeting Sign-Up

Physical Activity Readiness Questionnaire

Email drzacharyellis@gmail.com for additional scheduling times

Check your email for appointment confirmation!!!😄