Name
First Name
Last Name
DOB
Current age
Height
Weight
Sex
Address
Phone Number
Occupation
Email
Emergency Contact Name
Relationship
Emergency Contact Address
Emergency Mobile Phone
Emergency Home Phone
Emergency Work Phone
Name of Doctor
Doctor Phone Number
The appearance goal/s I aim to achieve from the exercise program is/are:
(please tick appropriate box/s)
The performance goal/s I aim to achieve from the exercise program is/are:
(please tick appropriate box/s)
The health goal/s I aim to achieve from the exercise program is/are:
(please tick appropriate box/s)
Why have you decided to hire a personal trainer?
(Mark more than one if applicable)
If other, why?
How would you rate your current physical status?
Are you currently physically active?
IF YES, what type?
How often? (frequency)
Have you been consistent?
IF NO, for what reason(s)?
How many sessions per week can you commit to?
What time of day would you prefer to exercise?
What kind of training would you prefer?
Would you prefer a particular trainer?
What are your personal barriers for not exercising or sticking to a program?
Are there any exercises you would prefer to see in your program? If yes, please state:
Do you smoke or use drugs?
Do you drink alcohol? If yes, how often?
How often do you eat out per week/month?
Are you easily stressed out?
IF YES, what are the causes?
Do you have a family history of cardiovascular disease?
Are you currently pregnant?
Have you recently given birth? If yes, how long ago?
Have you been hospitalised recently? If yes, for what reason?
Are you taking any prescribed medication?
Do you have any disabilities?
Have you had any injuries, major or otherwise?
Do you have any conditions that may effect your performance? If yes please state:
Do you, or have you ever suffered from any of the following (please tick):
Client signature (type name in caps)
Date signed:
