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Personal Training Form

indicates a required answer

1. *

First Name: 
2. *

Last Name:
3. *

Valid Email Address: 
4. *

Age:
5. *

Date of Birth:
6. *

Gender: 

 (1 required)
Male Female
7. *

Phone Number:
8. *

Emergency Contact Name:
9. *

Emergency Contact Phone #:
10. 

How did you hear about Personal Training?
11. *

How important are the following to you and your training program? (check all that apply)

 (1 required)
Learn safety and proper form Develop muscle
Lose body fat Develop a comprehensive routine
Rehabilitate and injury Sport specific training
Special needs (diabetes, arthritis, heart disease) Other
12. *

Is time an issue for you? If yes, please briefly explain.
13. *

Will you commit yourself to a training program that will get you into optimal shape and health?

 (1 required)
Yes No
14. *

Do you have any other concerns?
15. *

What are your main goals that you would like to accomplish during your training program? Be specific (e.g. pounds to lose or gain, pant size, % body fat, push ups, pull ups, running distance, etc.)
16. *

What rewards will you give yourself to staying on track?
17. *

Have you been involved in an exercise program before?
Yes No
18. 

If yes, what did you like most about the program?
19. *

Have you worked with a personal trainer before?
Yes No
20. *

If yes, was your experience positive?
Yes No
21. 

What did you like most about your training program?
22. *

When were you in the best shape of your life? How did you achieve it?

 
23. *

What activities are you currently involved in? (Please include cardio, aerobics, dance, sports, resistance training, and stretching etc.) 
24. *

What time fo day do you prefer to exercise?
25. *

How many days a week can you devote to exercise?
26. *

How many hours or minutes a day?
27. *

Do you eat breakfast?
Yes No
28. *

Do you eat within 2 hours of bedtime?
Yes No
29. *

How much water do you drink a day?

 (1 required)
1-2 cups 3-5 cups
6-8 cups 9-12 cups
30. *

Do you have low energy levels during they day? If yes, what time of the day?
31. *

Are you familiar with all the items on a food label?
32. *

Do you take vitamins or supplements?
33. *

Do you take any medications?

A personal trainer will contact you within the next business day to discuss training options and available dates.