CLIENT FORM Name * First Name Last Name Gender * Male Female N/A Age * Email * Weight * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What is the activity level at your job? * None( seated only ) Moderate (light activity, walking included ) High (heavy labor, very active) 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? * Has anyone of your immediate family developed heart disease before the age of 60? * yes no Do any diseases run in your family? yes no Please rate your readiness for change. * 1 2 3 4 5 Which following goals does best fit in with your goals Improved Health Improve Endurance Increased Strength Increased muscle Mass Fat loss What is your goal with your trainer? why? How often are you willing to train a week to reach your goal? * Have you trained with a personal trainer before * yes no Are you currently excersising regulary (at least 3x per week)? yes no At what times during the day would you prefer to train? Morning Mid-day Afternoon Evening Thank you!
