PTBYKG Consultation Form

Consultation Form

Congratulations on taking your first step towards improving your health and wellness! Please take a few minutes and fill out the form below to the best of your ability to help me to better understand your goals and current health and fitness status. Thank you!
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Your Location (City and State)
If in Jacksonville, FL, please specify which area of town you are located in.
Birthdate
How did you hear about me? (Google, Social Media, Referral, etc.)
What are your goals?

Improve nutritional and/or lifestyle habitsWeight lossToning and shapingStress reductionImprove appearanceImprove health (General)Improve cardiovascular enduranceImprove flexibilityImprove postureImprove muscular definitionImprove muscular sizeGain muscular strength/powerImprove self-esteem or confidenceImprove speedImprove sports performanceOther
Do you exercise regularly?
Rate your ability to perform cardio exercises:

Very LowFairAverageGoodExcellent
Rate your experience with resistance exercise:

BeginnerIntermediateAdvanced
What equipment do you have access to?

Free weights (dumbbell/barbells)Gym machines (Nautilus, Precor, Cybex, etc...)Cable weightsResistance bandsBosu ballsKettlebellsTRX bandsBowflexOther
Are you looking for training mornings, afternoons, or evenings?
On which days are you available to exercise?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Which type of program are you interested in?

In-Person TrainingHybrid Personal Training (Mix of in-person and online)Online Personal Training
Please answer YES or NO to the following questions:
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

YESNO
Do you feel pain in your chest when you perform physical activity?

YESNO
In the past month, have you had chest pain when you were not performing any physical activity?

YESNO
Do you lose your balance because of dizziness or do you ever lose consciousness?

YESNO
Do you have a bone or joint problem that could be made worse by a change in your physical activity?

YESNO
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

YESNO
Do you know of any other reason why you should not engage in physical activity?

YESNO
If you answered YES to the previous question, please explain:
If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered YES to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
Have you ever had any injuries or chronic pain? (If YES, please explain.)
Have you ever had any surgeries? (If YES, please explain.)
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, diabetes, or a bone disease? (If YES, please explain.)
Are you currently taking any prescription medication? (If YES, please list below.)
Do you smoke tobacco products?
Have you ever worked with a personal trainer before? If so, what was your experience like?
Any other comments about what you would like to see in your fitness plan?
Should be Empty: