Questionnaire & Goal Setting Form

Full Name*

First NameLast Name

Email*

Gender

MaleFemale

Date of Birth*

MonthDayYear

Age

years

Height

ft. inches

Weight

Lbs

Preferred Method of Contact*

Please provide preferred contact information (i.e. email address, phone number, etc.) *

How did you find me?*

(If you chose *Referral, who referred you?)

What do you do for a living?

*So I have a better understanding of the stress you're under every day

How would you describe your occupation activity level?

none(mostly sedentary)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?

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 in the last 6-12 months, please list them.

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

YesNo

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

YesNo

if yes please list:

Are you a current cigarette smoker?

YesNo

Your current nutrition plan could be best characterized as:

If neither, please describe your current nutrition plan

Please rate your readiness for change. (1-least ready, 10-totally ready)

Which of the following best describes what you want to accomplish?

If the previous descriptions doesn't do justice, please write a brief description of what you want to accomplish.

Why do you want to accomplish these goals. Please be explicit.

Expected timeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR	It'll take more than a year
NOW

Are you currently excersising regulary (at least 3x per week)?

YesNo

Have you trained with a personal trainer before?

YesNo

If yes what kind of training did you do:

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

MorningMid-DayAfternoonEvening

Which Service Do You Want To Apply For?*

Please Choose

If Personal Training, how many sessions do you intend to commit to?*

Please Choose

Are you Number 1 in your life??

If not, what are the most important things to you right now? Please list them in order.

I know it's a lot of questions, but this is the last one....what's your favorite movie? If not, top 3??

1. I acknowledge that I am training to achieve the goals I have put forth for myself and myself only.

2. I acknowledge that The Bloomington-Normal Athlete Factory|The Factory Bloomington-Normal | The PT Factory is a positive training environment. Any and all negative energy and emotion will be worked out before entering the gym or at least acknowledged with my trainer.

3. I acknowledge that my trainer and I are partners once we begin working together towards my goal(s).

4. I agree to let my trainer know if my goals change as they might, so we can begin making changes to the plan.

5. I acknowledge that I invest in the gym as much as I invest in myself. I promise to pick up after myself leaving the gym better than I found it.

6. I acknowledge that things might keep me from attending a training session. I agree to let my trainer know when I cannot make a training session within 12 hours of the time of appointment.

7. I acknowledge that late cancellations are acceptable when I: am physically ill, stuck at work, have an emergency (family, work, home, traveling issues).

Donovan's Personal & Accountability Coaching

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Client|Trainer Agreement