Personal Training Questionnaire

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Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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How did you hear about me?* This field is required.
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What is your current age?
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What is your current height, weight, and body fat (if known)?
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What is your occupation?
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What does your work week schedule look like?Hours, days, etc
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What services are you interested in?* This field is required.
Personal training
Nutrition coaching
Personal training and nutrition coaching
Online only personal training
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In general, what are your goals?* This field is required.Select all that apply
Lose weight/fat
Maintain weight
Add muscle
Improve physical fitness
Improve cardiovascular fitness
Have more energy
Get stronger
Improve athletic performance
Physique competition/modeling
Increase balance/flexibility
Improve sport specific skills
Add variety to exercise regime
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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!
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What barriers can you identify that may negatively impact your ability to reach your goals? ie: work, time, childcare, transportation, etc
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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.
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Who is going to be the most excited for you when you reach your goals?
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What have you tried in the past to lose weight? What specific workout programs or diets have you tried?
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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)
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If yes to children, how many and what are their ages?
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Fitness Related Questions
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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
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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
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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
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How many hours of sleep on average do you get per night?
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How would you rate the overall quality of your sleep?
I never wake up thru the night
I wake up sometimes thru the night
I wake up frequently thru the night
I have insomnia
I sleep with a CPAP machine
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How would you rate your overall energy throughout the dayAwake and alert, dragging and needing caffeine, etc
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How would you rate your overall stress level?
Low
Medium
High
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Do you have any joint pains, aches, joint injuries, or limitations?* This field is required.
YESNO
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If yes, please describe.* This field is required.
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What do you expect from me as your coach?
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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!
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Where do you plan on completing your workouts?
Gym facility
At home
Both gym and home
Other
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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.
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Lifestyle and Behavior Related Questions
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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
35
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
36
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
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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
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Do you regularly incorporate healthy fats into your day?Such as avocado or cheese for example
YESNO
39
How often do you eat foods high in saturated fat, refined sugar, and/or salt content?Please answer honestly
Less than one time a day
1-2 times a day
3-4 times a day
More than 4 times a day
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What do those foods usually consist of?E.g. chips, pop, fried foods, pizza, cookies, cakes, etc
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How many cups of coffee do you drink per day?
None
1-2
3-5
6-9
More; than 10
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Do you smoke?This includes e-cigs
YESNO
43
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.
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Do you drink alcoholic beverages?This is strictly a health related question- no judgement.
YESNO
45
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
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Physical Activity Readiness Questionnaire PAR-Q
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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
YESNO
48
Do you frequently have pains in your chest, when you perform physical activity?
YESNO
49
In the past month, have you had any pains in your chest when you were not doing physical activity?
YESNO
50
Do you lose your balance owing to dizziness or do you ever lose consciousness before, after, or during physical activity?
YESNO
51
Do you have any bone or joint conditions that may affect your exercise program?E.g. diabetes, epilepsy, back problems, respiratory ailments, etc
YESNO
52
Do you have any other medical condition that may affect your exercise program?Please explain below
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Have you been hospitalized in the last 6 months?
YESNO
54
Have you had recent surgery?
YESNO
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Are you trying to get pregnant, are pregnant, or given birth in the last 6 months?
YESNO
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If you answered "YES" to any of the above, please give more specific details (if not already explained above).
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Right now, are you taking any medications, either over-the-counter or prescription? Please list the medication and what it is for.
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Thank you for taking the time to complete this questionnaire. 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, if any obstacles arise.

Good luck and enjoy!

Nicole Pomerenke

Certified Personal Trainer

Certified Nutrition Coach
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Client Signature* This field is required.Please type your name below indicating all of the answers provided are honest and complete. After hitting submit it may give you an error message but I do receive your competed form. Once submitted I will be in touch with you to schedule your initial consult! Reminder the consult typically is $45.
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