Personal Training Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

3

Email* This field is required.

example@example.com

4

Phone Number* This field is required.

Area Code

Phone Number

5

Preferred method of communication

6

How did you hear about me?* This field is required.

7

What is your current age?

8

What is your current height, weight, and body fat (if known)?

9

What is your occupation?

10

What does your work week schedule look like?Hours, days, etc

11

What services are you interested in?* This field is required.

13

Please list 3-5 reasons WHY you want to make this change?* This field is required.Better health, running a 5K, keeping up with the kids, better work performance, etc. Really dig down deep and list the REAL reasons this is so important to you!

14

What barriers can you identify that may negatively impact your ability to reach your goals? ie: work, time, childcare, transportation, etc

15

On a scale from 1-10, 10 being you're willing to do anything to reach your goals, how motivated are you to change?* This field is required.

16

Who is going to be the most excited for you when you reach your goals?

17

What have you tried in the past to lose weight? What specific workout programs or diets have you tried?

18

Who else is also in your home?Select all that apply

Spouse or partner(s)

Roommate(s)

Child(ren)

Pet(s)

Other family (parent, grandparent, sibling, etc)

19

If yes to children, how many and what are their ages?

20

Fitness Related Questions

21

How often do you currently participate in active exercise?* This field is required.E.g. biking, running, swimming, lifting, etc

1-2 times a week

3-4 times a week

5-7 times a week

not in the last 3-6 months

22

How many hours do you spend participating in active exercise each day?This is purposeful and planned exercise

Fewer than 30 min

1-3 hours

30 min to 1 hour

3-5 hours

5-7 hours

More than 7 hours a day

23

Approximately how many hours a week do you do other types of physical activity?E.g. housework, walking to school/work, home repairs, gardening, etc

Fewer than 5 hours

10-14 hours

5-9 hours

15-19 hours

20 or more hours

24

How many hours of sleep on average do you get per night?

25

How would you rate the overall quality of your sleep?

26

How would you rate your overall energy throughout the dayAwake and alert, dragging and needing caffeine, etc

27

How would you rate your overall stress level?

28

Do you have any joint pains, aches, joint injuries, or limitations?* This field is required.

YESNO

29

If yes, please describe.* This field is required.

30

What do you expect from me as your coach?

31

Is there anything else you would like your coach to know?This can include anything that may affect your ability to complete your program or ways to help you stay motivated!

32

Where do you plan on completing your workouts?

Gym facility

At home

Both gym and home

Other

33

Do you have any workout equipment at home?What types of equipment do you plan on using or what can you use around your house? Do you plan to purchase any equipment? *not all programs need equipment, however.

34

Lifestyle and Behavior Related Questions

35

Do you regularly incorporate the recommended amount of vegetables into your day?Two to three cups of vegetables per day, including dark green, red/orange, starchy and other)

YESNO

36

Do you regularly incorporate the recommended amount of fruits into your day?Two (2) servings of fruit per day Examples of one fruit serving: One medium whole fruit, 1 cup cut-up fruit, 1 cup 100% fruit juice, ½ cup dried fruit

YESNO

37

Do you regularly incorporate the recommended amount of proteins into each day?Five and a half-ounce (5 ½-ounce) equivalents of protein per day including: 5 ounces per week of nuts, seeds, beans, peas or lentils 6 to 8 ounces per week of seafood, preferably oily fish such as salmon, mackerel, cobia, striped bass, herring or sardines

YESNO

38

Do you regularly incorporate the recommended amount of whole grains into your day?Six (6) servings of grains per day Examples of one serving of grains: One slice bread, One small tortilla, 1 cup ready-to-eat cereal flakes, 1 ounce (⅛ cup) uncooked pasta or rice, ½ cup cooked rice, pasta or cereal, 3 cups popped popcorn

YESNO

39

Do you regularly incorporate healthy fats into your day?Such as avocado or cheese for example

YESNO

40

How often do you eat foods high in saturated fat, refined sugar, and/or salt content?Please answer honestly

41

What do those foods usually consist of?E.g. chips, pop, fried foods, pizza, cookies, cakes, etc

43

Do you smoke?This includes e-cigs

YESNO

44

If yes, do you have plans for quitting?You don't need to quit, however if you do plan on quitting it plays an important role in your overall health.

45

Do you drink alcoholic beverages?This is strictly a health related question- no judgement.

YESNO

46

How often do you drink alcoholic beverages?This helps to establish how often a person is consuming beverages that contain a higher calorie content, especially if the goal is weight loss.

Never

1-2 times per week

3-4 times per week

Every day

Only on the weekends

Only every so often

47

Physical Activity Readiness Questionnaire PAR-Q

48

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YESNO

49

Do you frequently have pains in your chest, when you perform physical activity?

YESNO

50

In the past month, have you had any pains in your chest when you were not doing physical activity?

YESNO

51

Do you lose your balance owing to dizziness or do you ever lose consciousness before, after, or during physical activity?

YESNO

52

Do you have any bone or joint conditions that may affect your exercise program?E.g. diabetes, epilepsy, back problems, respiratory ailments, etc

YESNO

53

Do you have any other medical condition that may affect your exercise program?Please explain below

54

Have you been hospitalized in the last 6 months?

YESNO

55

Have you had recent surgery?

YESNO

56

Are you trying to get pregnant, are pregnant, or given birth in the last 6 months?

YESNO

57

If you answered "YES" to any of the above, please give more specific details (if not already explained above).

58

Right now, are you taking any medications, either over-the-counter or prescription? Please list the medication and what it is for.

59

Client Signature* This field is required.Please type your name below indicating all of the answers provided are honest and complete.

60

Thank you for taking the time to complete this questionnaire. It may give you an error message after you hit submit but I do receive your competed form. Your information will make it easier to design a program that suits your needs, fits your lifestyle, and includes activities that you enjoy! I will also know how to support you, should obstacles arise.

Nicole Pomerenke

Certified Personal Trainer

Certified Nutrition Coach