Personal Training Consultation Questionnaire

1
Full Name
First Name
Last Name
2
Date of Birth
Month
Day
Year
3
Age
years
4
Email
example@example.com
Email Verified
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5
Phone Number
Please enter a valid phone number.
6
Height
cm
7
Weight
KG
8
What do you do for a living?
9
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
10
Do you follow a regular working schedule, do you work days, afternoon or nights?
11
Please list the physical activities that you participate in outside of the gym and outside of work.:
12
If you have any diagnosed health problems list the condition(s).
13
If you are on any medications, please list them.
14
What additional therapies are being undertaken for the given health problem(s)?
15
If you have any injuries, please list them.
16
What additional therapies are being undertaken for the given injury?
17
Are you experiencing any stresses or motivational problems?
Yes
No
18
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
19
Please list:
20
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
21
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
22
What following goals does best fit in with your goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
23
What is your goal with your training?
24
TImeline for achieving your goal.
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
LIFESTYLE
NOW
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
NOW
8 WKS
Row 0, Column 0
16 WKS
Row 0, Column 1
24 WKS
Row 0, Column 2
32 WKS
Row 0, Column 3
40 WKS
Row 0, Column 4
1 YEAR
Row 0, Column 5
LIFESTYLE
Row 0, Column 6
25
Please rate your motivational level to do what it takes for reach your goal.
1
2
3
4
5
6
7
8
9
10
26
Have you trained with a personal trainer before?
Yes
No
27
At what times during the day would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
28
How often do you want to do Personal Training a week?
Please Select
Please Select
1 Session
2 Sessions
3 Sessions
4 Sessions
5 Sessions
6 Sessions
7 Sessions
Please Choose
29
1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client. (For 1 on 1 clients)

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) 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.
30
I AGREE TO THE ABOVE TERMS & CONDITIONS!
Yes
No
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