Personal Training Quesionnaire First Name *Last Name *Gender *MaleFemaleDate of Birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926Height *InchesWeight *PoundsWhat do you do for a living? *How is your activity level throughout the day? *None (not active)Moderate (light active/somewhat active)Active (on the go/very active)Do you follow a regular working/time schedule? And what times during the day is that? *How often do you travel? *RarelyA few times a yearA few times a monthWeeklyPlease list any physical activities you participate in.If you have had any diagnosed health problems, please list the condition(s)What additional therapies are being undertaken for the given health problems?If you have any injuries please list themWhat additional therapies are being undertaken for this given injury?Are experiencing any stresses or motivational problems?YesNoHas anyone of your immediate family developed heart disease before the age of 60?YesNoDo any diseases run in your family?YesNoAre you a current smoker?YesNoDo you suffer from any of the following?DiabetesAsthmaHigh Blood PressureLow Blood PressureHow would you best characterize your current diet?Low FatLow CarbHigh ProteinVegan or VegetarianNo Special DietPlease rate your readiness for change with a number 1-10Which of the following goals best fit in with your goals?Improved HealthImproved EnduranceIncreased StrengthIncreased Muscle MassFat LossWhat are your goals with your training and why are you doing this?Timeline for achieving your goals:8 Weeks16 Weeks24 Weeks32 Weeks40 Weeks1 YearHow often are you willing to train each week to reach your goals?Please rate your motivational level to do what it takes to reach your goal 1-10Are you currently exercising at least three times a week?YesNoHave you worked out with a personal trainer before?YesNoHow often do you want to do Personal Training a week?What are your expectations of me as your Personal Trainer and/or Nutritionist?Submit
