AS Personal Training

1

Name

First Name

Last Name

2

Phone Number

Please enter a valid phone number.

3

Email

example@example.com

4

How many sessions per week are you looking for?

1-2

3-4

5-7

7

How many hours of sleep do you get per night?

10+

7-9

4-6

3 or less

9

What does your diet mainly consist of?

Carbohydrates

Protein

Fat

Vegetables

10

Do you have any heart conditions?

YESNO

11

Do you lose your balance because of dizziness or ever lose consciousness?

YESNO

12

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity levels?

YESNO

13

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heartconditions?

YESNO

14

Do you know of any other reason why you should not do physical activity?

YESNO

15

Additional comments