Personal Training Questionnaire * Required FieldName* First Last Email* Phone*Age*Weight*Height*What do you do for a living?*What is the level of activity at your job?* None (seated only) Moderate (light activity) High (heavy labor, very active) Please list the physical activities you participate in currently:*Please list any diagnosed health issues:*What additional therapies are being undertaken for above health problems:*Please list any medications you currently take:*Do you have any injuries or limitations? If so, please list below:*Are you a current cigarette smoker?* Yes No How long have you been smoking?Describe your current diet?* Low Fat Low Carb High Protein Vegetarian/Vegan No special diet Please rate your readiness for change. (1 - lowest, 10 - Highest)* 1 2 3 4 5 6 7 8 9 10 What are your goals? And why?*What is your timeline for achieving your goal(s)?* 8 weeks 16 weeks 24 weeks 32 weeks 40 weeks 1 year How often are you willing to train a week to meet your goals(s)?*Please rate your motivational level to do what it takes to reach your goal. (1 - lowest, 10 - Highest)* 1 2 3 4 5 6 7 8 9 10 Are you currently exercising regularly (3x per week)?* Yes No Have you trained with a personal trainer before?* Yes No How often are you willing to train a week to meet your goal?*What times during the day would you prefer to train?*Comments / QuestionsWhat are your expectations on me as your personal trainer?*Additional comments:reCAPTCHA
