Maintenance Mode PT Client Intake

MMPT Physical Activity Readiness Questionnaire

Client Intake Form
Full Name*

First NameLast Name
Gender*

MaleFemale
Height
Inches
Weight
lbs
Phone Number*

Area CodePhone Number
Email*
example@example.com
How would you rate your overall health and wellness*

PoorBelow AverageAverageAbove AverageExcellent
Personal Medical History*

Back PainOverweight/ObesePre-Diabetes / DiabetesHigh Blood PressureHigh CholesterolHeart DiseaseTobacco UseOther
How would you rate your overall fitness level?*

BeginnerInermediateAdvanced
What is your current physical activity level?*

Minimally active (Very sedentary)Somewhat active(Light exercise)Moderately active (Intentional exercise 1-3 times/week)Very activeExtremely active
Have you ever followed a Training Program before?*

YesNo
Have you ever had a Personal Trainer before?*

YesNo
If yes, please explain:
How would you rate your current diet*

Poor (little fruit and vegetables, highly processed foods/fast food on a regular basis)Below averageaverage (some fruits and vegatables, processed foods, lean proteins, high fat protiensAbove AverageExcellent
How would you rate your overall nutrition education?*

BeginnerInermediateAdvanced
Describe your current workout program and dietary habits*
What are the top 3 goals you want to accomplish with MMPT?*
What is holding you back from achieving those goals?
Where do you hope to see yourself at the end of this training program?
Coach Danielle Casanova will be in contact within 24-48 hours once Client Questionnaire is submitted
Should be Empty:

MMPT Physical Activity Readiness Questionnaire

Coach Danielle Casanova will be in contact within 24-48 hours once Client Questionnaire is submitted