Personal Training Application

Personal Training Application
Part 1. Basic information
For Myself (18 and over), Minor (below 18), or Adult other than myself.*

MyselfMinor (17 and below)Adult other than myself
Full Name or Parent/Guardian Full Name*

First NameLast Name
Name of Minor (17 and below) or Adult other than myself*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Adult, or Parent/Guardian E-mail*
Phone Number*

Area CodePhone Number
Part 2. Personal Training Package
What package would you like to start with? (An estimate will be sent after submission)*

10 workouts16 workouts20 workouts
Part 3 . Personal Stats

Participant Stats
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
Example: 5'10"
Weight*
#
Part 4. Lifestyle Information
What do you do for a living?*
What is the activity level at your job?*

None(seated only)Light (teacher, nurse, doctor, etc)Moderate (waiter/waitress, retail, etc)High (heavy labor, constructions, etc)
Do you follow a regular working schedule, do you work days, afternoon or nights?*
How often do you travel?*

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.:*
Part 5. Medical and health information
If you have any diagnosed health problems list the condition(s). If none, answer N/A*
If you are on any medications, please list them.*
What additional therapies are being undertaken for the given health problem(s)? If none, answer N/A*
If you have any injuries, please list them. If none, answer N/A*
What additional therapies are being undertaken for the given injury? If none, answer N/A*
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
Are you a current cigarette smoker?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special dietOther
Part 6. Goals
Please rate your readiness for change.*

12345678910
What following goals does best fit in with your goals?*

Improve healthIncrease strengthIncrease muscle massWeight Loss (Fat loss)
What are your short term goals for the next month?*
What are your long term goals for the next 3+ months?*

Timeline for achieving your goal.*

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train on your own per week? *
Please rate your motivational level to do what it takes for reach your goal.*

12345678910
Are you currently excercising regularly (at least 3x per week)?*

YesNo
Have you trained with a personal trainer before?*

YesNo
If yes, what kind of training did you do? If no, answer N/A :*
What are your expectations on me as your Personal Trainer/Lifestyle Coach?*
Part 7: Days/Times
How often do you want to do Personal Training a week?*
Please Choose
Please list up to 5 available days and times in a typical week you are available for virtual and/or in-person. If in-app only, please answer N/A.*
Part 8. Initial Consultation
Where and when would you like to conduct your initial consultation? Even if it's in-app only, I still want you and I to get to know each other so please choose phone call, or Zoom etc.*
Address*

Name of Place (ex. Starbucks)

Address

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Time*

:HourMinutesAM/PM Option
Part 9. Equipment
Select what equipment you have access to:*
Please choose one:*

Please recommend me basic and necessary equipment to achieve my goal(s).Please help me build my garage or home gym.None of above at this time.
Additional equipment you have not listed above and/or comment you want to add:*
Can you give me some more information about your personal background and experiences? Specifically, I'm interested in hearing about your efforts to manage your weight. Have you attempted any specific diets or exercise programs in the past? Additionally, do you know what factors tend to contribute to overeating or unhealthy food choices for you? For example, do you find yourself reaching for comfort foods when you're feeling stressed or upset? Exploring your relationship with food and understanding your emotional triggers can be an important step in developing a sustainable weight management plan.
Please write your response here:*
Should be Empty:

Personal Training Application

Part 1. Basic information

Part 2. Personal Training Package

Part 3 . Personal Stats

Part 4. Lifestyle Information

Part 5. Medical and health information

Part 6. Goals

Part 7: Days/Times

Part 8. Initial Consultation

Part 9. Equipment