Maintenance Mode Personal Training Client Questionnaire

Name*

First NameLast Name
Email*
example@example.com
Gender*
Phone Number*

Area CodePhone Number
Weight (lbs)
Height (in)
How would you rate your overall health and wellness?*

PoorBelow AverageAverageAbove AverageExcellent
Personal Medical History?*

Back PainObese/OverweightPrediabetes/DiabetesHigh Blood PressureHigh CholesterolHeart DiseaseTobacco UseOther
What is your current physical activity level?*

Minimally active (very sedentary)Somewhat active (light exercise)Moderately Active (Intentionally exercise 1-3 times/week)Very ActiveExtremely Active
How would you rate your overall Fitness Level?*

BeginnerIntermediateAdvanced
Have you ever followed an Exercise Program before?
How would you rate your overall nutrition education?*

BeginnerIntermediateAdvanced
How would you rate your current diet?*

Poor (little fruit and vegetables, highly processed foods/fast food on a regular basis, high fat)Below AverageAverage ((some fruits and vegetables, processed foods, lean proteins, high fat proteins)Above AverageExcellent
Describe your current workout program and dietary habits*
What are your top 3 fitness goals that you would like to accomplish this year?*
What is holding you back from achieving those goals?
Where do you hope to see yourself at the end of this program?
Coach Danielle Casanova will be in contact within 24-48hours once Client Questionnaire is submitted
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Coach Danielle Casanova will be in contact within 24-48hours once Client Questionnaire is submitted