First Name*
Last Name*
Gender*
Date of Birth*
Age*
Height*
Weight*
What do you do for a living?*
What's the activity level at your job?* NoneModerate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule? If so, what does it look like?*
How many hours of sleep do you get each night, on average?*
What time is your ideal time of day to begin a workout?* Early mornings (5am-7am)Mornings (8am-10am)Mid-day (11am-1pm)Afternoons (2pm-4pm)Early evenings (5pm-7pm)Late evenings (8pm-10pm)
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.*
Do you have any diagnosed health problems? If so, please 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 stress or motivational problems?* YesNo
Do any diseases run in your family?* YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?* YesNo
Are you a current cigarette smoker?* YesNo
Your current diet could be best characterized as:* Low-fatLow-carbHigh-proteinKetoPaleoVegetarian/veganNo special diet
Please rate your readiness for change. 1 being very unlikely, 10 being very ready.* Selected Value: 6
What following goals best align with your goals? Please check all that apply.* Improved overall healthImproved enduranceIncreased strengthIncreased muscle massFat lossBeing held accountable to show up
What is your goal with working with a private trainer?*
Why?
How often are you willing to workout a week to reach your goal?*
Please rate your motivational level to do what it takes to reach your goal. 1 being very unmotivated, 10 being very motivated.* Selected Value: 6
Are you currently exercising regularly (at least 3x per week)?* YesNo
Have you trained with a personal trainer before?* YesNo
At what times during the day would you prefer to train?*
How often do you want to do Personal Training a week?* 1x per week2x per week3x per week4x or more per week
What are your expectations with working with a personal trainer?*
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Check The Training Program(s) You Are Most Interested In Weight LossHIITYogaPilatesPrenatal/PostnatalStrength / Resistance TrainingLow Impact Training Workouts Name*
Email* Phone*
Questions or Comments Submit
