First name

Last name

MaleFemale

Date of birth

Age

Height (in cm)

Weight (in kg)

What do you do for a living?

Whats the activity level at your job?
Low (seated only)Moderate light activity such as walking)High (heavy labor, very active)

Do you follow a regular working schedule, do you work days, afternoon or nights?

Do you travel often?
RarelyA few times a yearA few time a monthWeekly

Please list the physical activities that you participate in outside of the gym and outside of work:

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

YesNo

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

YesNo

Do any diseases run in your family?

YesNo

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

YesNo

Are you a current cigarette smoker?

YesNo

Your current diet could be best characterized as:
Low-fatLow-carbHigh proteinVegetarianVeganNo special diet

Please rate your readiness for change.

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What following goals does best fit in with your goals?
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss

What is your goal with your training?

Why?

Timeline for achieving your goal.
8 weeks16 weeks24 weeks32 weeks40 weeks1 year

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.

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

YesNo

Have you trained with a personal trainer before?

YesNo

At what times during the day would you prefer to train?

MorningMid-dayAfternoonEvening

How often do you want to do Personal Training a week?
1 session2 sessions3 sessions4 sessions5 sessions6 sessions7 sessions

What are your expectations on me as your Personal Trainer?

Your email

Phone number