Personal Training Client Questionnaire

- TAILORING OUR PERSONAL TRAINING TO YOU -

Please contact us (feel free to send a message, call, or email) before starting and/or completing your personal training client questionnaire. This questionnaire is designed to help us create customized programs that will address your needs and goals while considering your safety. All information received will be strictly confidential.

Don't have time to fill out the entire form? Scroll down to the bottom of this page and select "Save and Continue Later."

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Section 1: About You

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact*

First Last

Relationship*

Emergency Contact Phone*

Physician's Name*

First Last

Physician's Phone*

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?*

Yes

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

Yes

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

Yes

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

Yes

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.)?*

Yes

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

Yes

Have you had a recent surgery?*

Yes

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

Yes

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

Section 3: About Your Lifestyle

Do you smoke?*

Yes

How many hours do you regularly sleep at night?*

Please enter a number from 0 to 24.

Describe your day to day lifestyle:*

Sedentary

Active

Physically Demanding

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?*

Mother

Father

Sibling

Grandparent

N/A

Check all that apply.

Were you overweight as a child?*

Yes

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?*

Yes

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?*

Yes

Do you eat breakfast?*

Yes

How many glasses of water do you consume daily?*

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

Yes

Section 6: Your Exercise History

How often do you take part in physical exercise?*

5-7 times per week

3-4 times per week

1-2 times per week

I am not presently active

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

Lack of Interest

Illness/Injury

Lack of Time

Other

Check all that apply.

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?*

Large Groups

Small Groups

Alone

Combination

When would you prefer to exercise?*

Morning

Afternoon

Evening

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?*

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Check all that apply.

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?*

Very Important

Important

Not Very Important

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.?*

Posters

Brochure

Website

Newspaper/Magazine Column or Ad

Already know Chad

Word of Mouth Referral

Other

Check all that apply.

Please elaborate on the selection you made above.