Personal Training/Fitness Coaching Consultation Questionnaire

Personal Training Consultation Questionnaire
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you understand Coach Rho and the Dynamic Duo Fitness team will review this form and proceed with the consultation if the application meets the basic requirements of our programs?

Yes___

An offer to join one of our programs will only be made if Coach Rho and the Dynamic Duo Fitness team can help you. Do you want to proceed?

Yes___
Gender

FemaleMale
Date of Birth

MonthDayYear
Height
Inches
Weight
Lbs
What do you do for a living?
Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular work schedule? Do you work days, afternoon or nights?
Do you have any diagnosed health problems? List the condition(s).
Please list the physical activities that you participate in outside of the gym and outside of work:
If you are on any medications, please list them.
If you have or have had any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesSometimesNo
Has anyone in your immediate family developed heart disease before the age of 60?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Please rate your readiness for change. (1 - meaning not ready 10- meaning very ready)

12345678910
Which of the following goals best fit your goals?

Improved healthLoss inchesIncreased strengthIncreased muscle mass/Lower BMIFat loss
What is your goal for your fitness training?
Why?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently exercising regulary (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
What kind of training did you do?
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?
Please Choose
What are your expectations for Coach Rho and the Dynamic Duo Fitness Coaches as your Personal Trainers?
Dynamic Duo Fitness training programs can start at $499. If an offer is made to join one of our fitness programs, are you prepared to move forward?*

*Not applicable for Personal Training sessions.
YesNo
What makes you a good fit for Coach Rho and Dynamic Duo Fitness' training programs?
ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
Should be Empty:

Personal Training Consultation Questionnaire