Dave's Personal Training Consultation Questionnaire

Full Name*

First NameLast Name

Gender*

MaleFemale

Date of Birth*

MonthDayYear

Age

years

Height*

Inches

Weight*

lb

Day Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail

What is the best way to make contact with you?

What do you do for a living?

Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)

Do you follow a regular working schedule, do you work days, afternoon or nights?

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.:

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?

YesNo

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

YesNo

Do any diseases run in your family?

YesNo

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

YesNo

if yes please list:

Are you a current cigarette smoker?

YesNo

Your current diet could be best characterized as:

Which of the following goals best fit in with yours (select all that apply)?

Other fitness goals if not selected above:

What is your goal with your training?

Why?

Timeline for achieving your goal.

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

How often are you willing to work with a trainer each week?

How often are you willing to workout by yourself a week given a specific plan to follow?

Describe the last time you participated in a structured exercise program:

What personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?

Do you currently exercise on a regular basis?

YesNo

If yes, how many days a week?

How long is each session in minutes?

What equipment do you have access to?

What days are you available to train?

At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening

Have you trained with a personal trainer before?

YesNo

If yes, what kind of training did you do?

If yes, was your previous experience negative or positive? Why?

Describe your ideal personal trainer/What do you expect of me as your personal trainer?

Anthropometrics (Body measurements)

Chest*

Inches

Hips*

Inches

Lower Leg*

Inches

Neck*

Inches

Thigh*

Inches

Upper Arm*

Inches

Waist*

Inches

Average Daily Activity For The Day*

Explain how you believe your diet is affecting your health goals:

List your top 3 nutrition questions or goals:

Have you had any recent weight gain or loss?

YesNo

If yes, please explain:

Please rate your readiness for change.

Please rate your motivational level to do what it takes to reach your goal.

Describe something you are looking forward to in the near future:

How do you want to feel at this time?

How do you want what you are doing right now to influence this event?

What energizes you in the present? Think about a recent moment when you were happy! What was it about that moment that made it good for you?

What motivates you?

Need a strong motivator to push you to exerciseYou like to be informed about your program and how it is going to lead you to your goalsLike to try new things if they are effectiveWilling to push past your comfort level to reach your goalsf I feel things are really hard I tend to back offNeed to be held accountable for what I am doingBeing sore the day after a workout tells me my workouts are working

1.) CANCELLATIONS

The personal trainer reserves the right to charge you for a training session if you do not give at least a 24-hour cancellation notice. This session will be classified as a "NO SHOW SESSION" and will be deducted from your session balance.

If you become aware that you cannot make a scheduled appointment, leave a detailed message at the contact number chosen by your trainer.

2.) LATE ARRIVALS

Each session shall be 30 mintes - 1 hour in length as initially agreed upon by the client and trainer. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) LIABILITY

In recognition of the possible dangers connected with any physical activity, the client hereby knowingly and voluntarily waives any right of cause of action of any kind whatosever arising from any liability which may or could accrue to the club, its officers, agent's employees or instructors.Should client default, client agrees to pay all costs of collection, including agency fees, court costs and reasonable attorney fees, all of which may be paid or incurred by the holder of this note. Client agrees that no other representation is made other than that which is agreed to in writing.

Failure to use all personal training sessions or follow program will not relieve client payment. If original trainer is unable to complete session, Sixel's USA Martial Arts and Fitness has the right to assign another trainer. No refunds will be given.

4.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

I agree to the above terms and conditions!*

Yes

Signature*

Date*

Personal Training Consultation Questionnaire

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Part 5. Nutritional Plan

Part 6. Mental Readiness/Personality

Part 7. Services Offered

Please Read The Following T&C's.