Personal Training Consultation Questionnaire

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 Name Last Name

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

First Name Last Name

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail*

Phone Number*

Area Code Phone Number

Gender*

MaleFemale

Date of Birth*

Month Day Year

Age*

years

Height*

Example: 5'10"

Weight*

#

What do you do for a living?*

What is the activity level at your job?*

None(seated only)Light (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.:*

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

Are you a current cigarette smoker?*

YesNo

Your current diet could be best characterized as:*

Please rate your readiness for change.*

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

What are your short term goals for the next month?*

What are your long term goals for the next few 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.*

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?:*

What are your expectations on me as your Personal Trainer/Lifestyle Coach?*

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.*

Where would you like to conduct your initial consultation?*

Address*

Name of Place (ex. Starbucks)

Address

City State / Province

Postal / Zip Code

Date*

Date

Time*

:Hour Minutes AM/PM Option

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:*

Adult or Guardian: By signing here, I have read and agreed with the waiver.*

Clear

Minor: By signing here, I have read and agreed with the waiver*

Clear

Date*

MonthDay Year

RESCHEDULING POLICY:
You may not cancel your scheduled session. However, you may reschedule with in allowed days. If you need to reschedule a session, please contact/text me at 408-674-9239. 24 hours’ notice is required for a rescheduling in order to receive credit for the session. Failure to reschedule within this time frame (You may only reschedule your session within one week after your missed session) or failure to show up for a session will result in the client being charged for the session. There is a no-refund policy on all packages purchased.

***I'm booked almost 100% so rescheduling maybe hard and it's not guaranteed. You may only reschedule your session within one week after your missed session.***

TARDINESS POLICY:

Clients are expected to begin working out at the start time of the scheduled
appointment. A late start time does not entitle a client to a session longer than the
scheduled appointment.

If you are going on vacation or be out of town, please contact me as soon as possible. Two weeks notice is required.

***All packages/sessions are to be paid in advanced prior to workout.***

Adult or Guardian: By signing here, I agree to the terms and conditions above.*

Clear

Date*

MonthDay Year

Personal Training Consultation Questionnaire

Part 1. Basic information

Part 2. Personal Stats

Part 3. Lifestyle Information

Part 4. Medical and health information

Part 5. Goals

Part 6: Days/Times

Part 7. Initial Consultation

Part 8. Equipment

Part 9. Waiver

Part 9. Terms and Conditions