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.

Gender

Date of Birth

MonthDayYear

Age

years

Height

ft/in

Approximate Weight

lb

What do you do for a living?

Whats the activity level at your job?

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.

Are you a current smoker?

Your current diet could be best characterized as:

Please rate your readiness for change.

What following goals does best fit in with your goals?

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?

Are you currently excersising regulary (at least 3x per week)?

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

Have you trained with a personal trainer before?

At what times during the day would you prefer to train?

Please pick an available date/time for your Full Body Assessment below:

Please include secondary date and time: