Name
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First Name
Last Name
Date Of Birth
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MM
DD
YYYY
Age
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
###
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Email Address
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How did you hear about us?
Emergency Contact, Relationship
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Emergency Contact Phone
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(###)
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Physician's Phone
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(###)
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Physician's Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
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Do you frequently have pains in your chest when you perform physical activity?
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Have you had chest pain when you were not doing physical activity?
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Do you lose your balance due to dizziness or do you ever lose consciousness?
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Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
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Are you pregnant now or have given birth within the past 6 months?
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Have you had a recent surgery?
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If you have marked YES to any of the above, please elaborate below:
Do you take any medications; wither prescription or non-prescription, on a regular basis?
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What is the medication for?
How does this medication affect your ability to exercise or achieve your fitness goals?
When you were in the best shape of your life?
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Have you been exercising consistently for the last 3 months?
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When did you first start thinking about getting in shape?
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What, if anything, stopped you in the past?
On a scale of 1-10, how would you rate your present fitness level (1=worst 10=best)?
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How often do you take part in physical exercise?
2) If your participation is lower than you would like it to be, what are the reasons?
If other, please describe:
How long have you been consistently physically active for?
What Cardio/Sports Activities are you presently involved in?
List Frequency/Week, Average Length of Time and Rank Easy/Moderate/Hard
What Strength Training activities are you presently involved in?
List Frequency/Week, Average Length of Time and Rank Easy/Moderate/Hard
What Flexibility activities are you presently involved in?
List Frequency/Week, Average Length of Time and Rank Easy/Moderate/Hard
If you could design your own exercise program, what would an ideal training week look like to you? Please be specific. List your favorite activities, rest days, time spent etc...
How can a personal trainer help you? Please check all that apply.
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If other, please describe:
Please list in order or priority, the fitness goals you would like to achieve in the next 3-12 months?
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How will you feel once you've achieved these goals? Be specific.
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Where do you rate health in your life?
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How committed are you to achieving your fitness goals?
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What do you think is the most important thing we can do to help you achieve your fitness goals?
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Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation plans, busy season at work, not following the program, allowing other responsibilities to become priority over exercise etc.)
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7. Outline 3 methods that you plan to use to overcome these obstacles:
