Form

- Step 1 of 4

Personal Information

Date

Name *

First

Last

Gender *

Male
Female

Age *

Height *

Weight *

Phone Number

Email *

Lifestyle Information

What do you do for a living?

How much would you rate your level of physical activity at work? *

1 (not active)
2
3
4
5 (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:

Medical and health information

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? *

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

Do any diseases run in your family ? *

If yes please list:

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

If yes please list :

Do you smoke ? *

Your current diet could be best characterized as : *

low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet

Goals

On a scale from 1-10 how motivated are you to make changes ? *

Checkboxes *

Improved health
Improved endurance
Increased energy
Increased strength
Increased muscle mass
Fat loss
Improved mood

What is your main goal regarding your training ? Short term and long term goal *

What is your main goal regarding your health and well-being? *

Do you have injuries, allergies or intolerances? If yes please elaborate *

Timeline to achieve goal : *

How often are you currently training ? *

How often are you willing to train a week to reach your goal ? *

Have you trained with a personal trainer before? *

If yes what kind of training did you do:

What is the best time for you to train ? *

Morning
Mid-Day
Afternoon
Evening
Any

Name

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