Personal Training Request For

Name

Birthday

Contact Phone Number:

Can we text you at this phone number?

Yes

ACTIVITY HISTORY

Are you currently recreationally active?

Yes

If not currently active, have you ever participated in a regular fitness or sports activity? If yes, when and for how long?

What sports or activities do you participate in? Please include the type and frequency of your physical activities, including those of daily living (for example: gardening, walking, etc.)

Are you involed in a cardiovascular training program?

Yes

Are you involved in a strength training/weight lifting program?

Yes

Do you have any previous injuries that impact your ability to perform certain activities? If so, please describe the injury and limitations:

Are you currently taking any medications?

Certain classes of medication alter the body's response to exercise

Do you have a preference of the gender of your trainer?

Female

Male

No Preference

Do you have a specific trainer you would like to work with?

What general time frame would you like you trainer to be available?

5:00 am - 9:00 am

9:00 am - noon

noon - 4:00 pm

4:00 pm - 8:00 pm

8:00 pm - 11:00 pm

Choose 1 or more time frames

How many sessions would you like to schedule on a typical week?

1 session per week

2 sessions per week

3 sessions per week

4 sessions per week

5 sessions per week

What days would you like your trainer to be available?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How many sessions would you like to purchase?

1 session

5 sessions

10 sessions

20 sessions

Specific Fitness Goals

Strength

Flexibility

Improve Health/ Exercise Habits

Cardiovascular Fitness

Lose weight/ Body Fat %

Gain Weight/ Size

Prevent Injury

Rehabilitate Injury

Sports Performance

Do you have any concerns about your weight? Please explain:

Have you ever tried to lose/gain weight in the past? If yes, how did you go about it or what program did you use? How successful were you while trying to gain/lose weight?

If NO, please move on to next question

Have you ever used tobacco prodcuts in the past? When did you stop?

If you are using tobacco products, are you interested in quittting?

Yes

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