Personal Training Consultation Form

Full Name*

First NameLast Name

Date of Birth*

MonthDayYear

Age

Height

ft

Current Weight

Phone Number

Email

example@example.com

How do you prefer to be contacted?

Please select the service you are requesting:

In person, one on one trainingOnline Coaching

What is your goal with your training? Why is this goal important for you to achieve or work towards?

What is your current job occupation?

What is the activity level at your job?

none (seated only)Moderate (light activity such as walking)High (heavy labor, very active)

Have you tried to achieve this goal in the past and had struggles or barriers?

YesNo

If you have any prior injuries, please list them below:

If you are on any medications, please list them below:

Have you been diagnosed with PCOS, insulin resistance, pre/ diabetes, asthma, high blood pressure, endometriosis, hypothyroidism, hashimoto, etc?

YesNoOther

Please list all diagnosis and when the diagnosis was received:

Have you had hormone labs done? If so, how long ago?

Please description your nutrition habits and how you feel your relationship with food is:

Have you trained with a personal trainer before?

YesNo

How many sessions are you interested in weekly? Do you have preferred days and times you would like to train?

Please list what your expectations would be if I was your personal trainer: