Personal Training Consultation Questionnaire

Full Name*

First NameLast Name
Gender

MaleFemaleNon-Binary
Date of Birth*

MonthDayYear
Age
years
How did you hear about Mo Fit?
Height
Ft and in
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)
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
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)?
Do you have any current or previous injuries? Please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
if yes please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
What following goals best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What are your fitness goals?
What is your "why"?
Are you currently exercising regularly (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
If yes what kind of training did you do:
Which training option(s) are you interested in?

Small Group TrainingOne on One TrainingNutrition CoachingVirtual Training
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
What day(s) of the week would best accommodate your schedule? Choose all that apply.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What are your expectations of me as your Personal Trainer?
Email
example@example.com
Phone Number

Area CodePhone Number
How did you hear about us? If referred by a client, please name them
Waiver
I First Name* Last Name* HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN
ANY/ALL ACTIVITIES ASSOCIATED WITH TRAINING WITH Al moni Ellis. I accept all
responsibilities for any injuries that may occur while training and fully understand
that Al moni Ellis is not liable for any injuries or accidents. Date* Signature*
I First Name* Last Name* understand that all training information that is accessible to me is
of the property of Al Moni Ellis and I will not share this content with others. Date* Signature*
Cancellation Agreement
I First Name Last Name understand that as a new client, I agree to a minimum of a 3 month commitment. This means, I am obligated to pay for the service that I signed up for with
Mo Fit for the next 3 months. Payment is due monthly, on the day of the month
training began. After I have completed 3 months I will move to a month to month membership with the cancellation policy listed below. Date Signature
I First Name Last Name agree to place my card on file via square and I acknowledge that to cancel my membership, after my initial 3 month commitment, that I need to notify Mo Fit
(Almoni Ellis) via email, 30 days prior to my next payment. Should I fail to do so, I accept
that I am still liable for the next upcoming payment, and I agree to submit the upcoming
payment upon it's due date. Date Signature
ALL THE INFORMATION I HAVE GIVEN IS CORRECT
All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Signature

Clear
Should be Empty:

Waiver

Cancellation Agreement