MMPT Physical Activity Readiness Questionnaire
Client Intake Form
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Height
Inches
Weight
lbs
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
How would you rate your overall health and wellness
*
Poor
Below Average
Average
Above Average
Excellent
Personal Medical History
*
Back Pain
Overweight/Obese
Pre-Diabetes / Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Tobacco Use
Other
How would you rate your overall fitness level?
*
Beginner
Inermediate
Advanced
What is your current physical activity level?
*
Minimally active (Very sedentary)
Somewhat active(Light exercise)
Moderately active (Intentional exercise 1-3 times/week)
Very active
Extremely active
Have you ever followed a Training Program before?
*
Yes
No
Have you ever had a Personal Trainer before?
*
Yes
No
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 average
average (some fruits and vegatables, processed foods, lean proteins, high fat protiens
Above Average
Excellent
How would you rate your overall nutrition education?
*
Beginner
Inermediate
Advanced
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 will be in contact within 24-48 hours once Client Questionnaire is submitted
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