Date (mm/dd/yyyy)

Your Name (required)

Your Email (required)

Your Phone


FITNESS

1. What are your goals? Please be specific.

2. What is your occupation?

3. What does your current exercise regimen consist of?

4. Have you had a Personal Trainer before?

5. If you answered yes to question 4, what did you like about the Personal Trainer?

6. If you answered yes to question 4, what did you dislike about the Personal Trainer?

7. What kinds of exercise do you like?

8. What pieces of exercise equipment do you like?

9. What kinds of exercise do you dislike?

10. What pieces of exercise equipment do you dislike?

11. Please list any past injuries and surgeries and their approximate date.

12. Please list any current injuries or areas in which you feel pain.

13. Are you currently taking any medications? EX: antidepressant, sleeping pill, etc.

14. What days and time frames on those days do you prefer to workout? We are available Monday through Saturday and will do our very best to accommodate your preferences. EX: Mondays and Wednesdays between 9 AM and 1 PM.


NUTRITION

1. Are you currently on a Nutrition Plan? If so, please explain your regimen.

2. If you answered yes to question 1, is your current Nutrition Plan working?

3. If you answered yes to question 1, is your current Nutrition Plan one you can maintain for the rest of your life?

4. What types of diets have you tried in the past?

5. Have you ever had a Nutritionist?

6. If you answered yes to question 5, what did you like about the Nutritionist?

7. If you answered yes to question 5, what did you dislike about the Nutritionist?

8. Are you currently taking any supplements?

9. What supplements have you taken in the past (only if different from answer to question 8)?

10. What current issues do you have with food (if any)? EX: anorexic, bulimic, emotional eating, etc.

11. What past issues have you had with food (if any)? EX: anorexic, bulimic, emotional eating, etc.

12. Do you have any allergies to foods? If so, please list them.

13. What foods do you like?

14. What foods do you dislike?

15. What restaurants do you like?

16. Is there anything we forgot to ask that you would like to tell us?