Personal training questionnaire

Name *

First

Last

Email *

Phone number (optional)

Gender *

Male
Female

Date of Birth *

Height (inches) *

Weight (lbs) *

What do you do for a living? *

What’s the activity level at your job? *

None (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? *

How often do you travel? *

Rarely
A few times a year
A few times a month
Weekly

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

Please list the condition(s) if you have any diagnosed health problems: *

Please list any medications if you are 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? *

Yes
No

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

Yes
No

Do any diseases run in your family? *

Yes
No

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

Yes
No

If yes please list:

Are you a current cigarette smoker? *

Yes
No

Your current diet could be best characterized as: *

Please rate your readiness for change (1 - None, 10 - Completely ready)

Selected Value: 5

What following goals does best fit in with your goals? *

What is your goal with your training? *

Why? *

Timeline for achieving your goal: *

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. (1 - None, 10 - Completely ready)

Selected Value: 5

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

Yes
No

Have you trained with a personal trainer before? *

Yes
No

If yes, what kind of training did you do?

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

Morning
Mid-Day
Afternoon
Evening

How often do you want to do personal training a week? *

What are your expectations on me as your Personal Trainer? *

Personal Training Questionnaire