Chad Pines' Personal Training Studio

Virtual Personal Trainer with a Customized 6 Week Training Program

Personal Training Client Information Questionnaire

All information received will be treated as strictly confidential. Please fill out the form completely and accurately. This information will allow me to design programs that address your needs/goals while considering your safety.

Section 1: About You

Name*:

Date of Birth*:

Address*:

Address 2:

City/State/Zip Code*:

Phone*:

Email*:

Emergency Contact*:

Relationship*:

Emergency Contact Telephone*:

Physician's Name and Telephone*:

Section 2: About Your Health

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*


Do you feel pain in your chest when you perform physical activity?*


Have you had chest pain when you were not doing physical activity?*


Do you lose your balance due to dizziness or do you ever lose consciousness?*


Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?*


Are you pregnant now, or have you given birth within the last 6 months?*


Have you had a recent surgery?*


Do you take any medications, either prescription or non-prescription, on a regular basis?*



If you have marked YES to any of the above, please elaborate below.*

Section 3: About Your Lifestyle

Do you smoke?*


How many hours do you regularly sleep at night?*

Describe your day to day lifestyle:*



On a scale of 1-10, how would you rate your stress level?*


1 = Very Low, 10 = Very high


List your 3 biggest sources of stress:*



Is anyone in your family overweight?*




Were you overweight as a child?*


Section 4: Your Fitness History

When were you in the best shape of your life?*

Have you been exercising consistently for the past 3 months?*


When did you first start thinking about getting into shape?*

What, if anything, stopped you in the past?*

On a scale of 1-10, how would you rate your present fitness level?*


1 = Worst, 10 = Best

Section 5: Your Nutrition

On a scale of 1-10, how would you rate your nutrition?*


1 = Very Poor, 10 = Excellent

How many times a day do you usually eat (including snacks)?*

Do you skip meals?*


Do you eat breakfast?*


How many glasses of water do you consume daily?*

Do you feel drops in your energy levels througout the day?*


Section 6: Your Exercise History

How often do you take part in physical exercise?*




If your participation is lower than you would like it to be, what are the reasons?*




For how long have you been consistently physically active?*

What CARDIO/SPORTS activities are you currently involved in? For each entry, please answer the following questions: How many times per week? How long is each session? What is the level of difficulty?*

What STRENGTH TRAINING activities are you currently involved in? For each entry, please answer the following questions: How many times per week? How long is each session? What is the level of difficulty?*

What STRETCHING activities are you currently involved in? For each entry, please answer the following questions: How many times per week? How long is each session? What is the level of difficulty?*

Section 7: Developing Your Fitness Program

How would you prefer to exercise?*





When would you prefer to exercise?*




Realistically, how often a week would you like to exercie?*

What are the best days during the week for you to commit to your exercise program?*








Do you own any equipment to use in your workouts? Ie. Treadmill, weights, tubing?*

Where do you plan to do your workouts? Home (which room), outside, gym, etc?*

Do you have access to stairs, hiking trails, hills to include in your exercise program?*

Are there any exercises you love or hate? (ie. love jumping jacks, hate push-ups)*


Section 8: Setting Your Goals

Please list, in order of priority, the the fitness goals you would like to achieve in the next 3-12 months.*

How important is it for you to achieve these goals?*



How long have you been thinking about achieving these goals?*

How will you feel once you've achieved these goals? Be specific.*

What do you think is the most important thing a Personal Trainer can do to help you achieve your fitness goals?*

Section 9: Miscellaneous Questions

How did you hear about Pines Fitness Consulting, LLC.?







Please elaborate on the selection you made above.*

Section 10: Participant Release And Knowledge Of Agreement

I wish to participate in the exercise and training program offered by Pines Fitness Consulting, LLC. (PFC). I understand there are inherent risks in participating in a program of strenuous exercise; consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. If I choose not to see a physician prior to beginning a fitness program, I do so strictly at my own risk and against recommendation of PFC. I also agree to provide PFC with my physician’s contact information so that PFC may receive direct clearance and program recommendation/limitations from my physician. I further agree that PFC, Chad Pines and/or any fitness professional working with PFC shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, in a training studio, outdoors, or at a corporate, commercial, residential or other fitness facility), and I expressly release and discharge PFC, its owners, employees, agents and/or assigns from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.*

I have read and understand this term.


I certify that the answers to the questions outlined on the About Your Health form are true and complete to the best of my knowledge. I acknowledge that medical clearance is requested if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform PFC of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.*

I have read and understand this term.


I understand that I am not obligated to perform nor participate in any activity that I do not wish to do. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and seek medical attention, if required.*

I have read and understand this term.


I understand the results of any fitness program cannot be guaranteed and my progress depends on my own effort and cooperation with the fitness program. *

I have read and understand this term.


I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by PFC.*

I have read and understand this term.


I understand that PFC may photograph client events/sessions and I provide PFC the absolute right and permission to use these pictures/images for any lawful promotional, advertising or marketing purpose. (optional)

I have read and understand this term.


I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.*

I have read and understand this term.


I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.*


Indicate your agreement by typing your full name.

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