Personal Training Intake Questionnaire

Personal Training Intake Questionnaire
Full Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemale
Date of Birth*

MonthDayYear
Age
years
Height
ft/in
Approximate Weight
lb
What do you do for a living?
None(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
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 have any injuries, please list them.
YesNo
Low-fatLow-carbHigh-proteinVegetarian/VeganUnhealthy Diet
12345678910
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?
What is your motivation for change?

TImeline for achieving your goal.*

Rows	8 WKS	12 WKS	16 WKS	24 WKS	36 WKS	+1 YEAR
NOW

How often do you want to do Personal Training per week?*
Please Choose
How often are you willing to train on your own per week to reach your goal?*
YesNo
What kind of training style do you participate in?
What kind of at-home modalities do you own? (Include type, weight and count)
ex. Dumbbells / 10 lbs / 1 pair
Do you have access to a gym?
Please explain if it is a Clubhouse Gym, At-home Gym or Membership Gym
YesNo
MorningMid-DayAfternoonEvening
Please pick an available date/time for your Full Body Assessment below: *
Please include secondary date and time:
Should be Empty: