Surveypoint

Q1

Full Name*

First Name

Q2

Full Name*

Last Name

Q3

Gender*

Q4

Date of Birth*

Month

Q5

Date of Birth*

Day

Q6

Date of Birth*

Year

Q7

Age*

Q8

Height*

Q9

Weight*

Q10

Address*

Street Address

Q11

Address*

Q12

Address*

City

Q13

Address*

Zip Code

Q14

Address*

State

Q15

Phone Number*

Phone Number

Q16

Email*

example@example.com

Q17

What is the best way to contact you?*

Q18

What do you do for a living?*

Q19

What is the activity level at your job?*

Q20

Do you follow a regular working schedule, do you work days, afternoon or nights?*

Q21

How often do you travel?*

Q22

How would you rate the stress of your job?*

Q23

How would you rate the stress of your lifestyle?*

Q24

What are your hobbies, or what do you like to do in your spare time?*

Q25

Has your doctor ever said you have a heart condition?*

Q26

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?*

Q27

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*

Q28

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

Q29

If yes to the above question, please list the condition(s) here.

Q30

Are you currently taking prescribed medications for a chronic medical condition?*

Q31

If yes to the previous question, please list your medications and how long you have been taking them.

Q32

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?*

Q33

If yes to the above question, please explain the condition.

Q34

Has your doctor ever said you should only do medically supervised physical activity*

Q35

Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?*

Q36

If Yes to the question above, please list reason here.

Q37

If you are on any medications not previously mentioned, including multivitamins,please list them here, including how long you have been taking them. Enter none if none.*

Q38

If you have any diagnosed health problems not previously mentioned, please list the condition(s) here. Enter none if none.*

Q39

Please list any injuries or surgeries you have had in the past five years. Enter none if none.*

Q40

Has anyone of your immediate family developed heart disease before the age of 60?*

Q41

Do any diseases run in your family?*

Q42

If yes to the above question, please explain.

Q43

Do you suffer from or have a history of:*

Q44

If yes to any of the above, please explain here.

Q45

Are you a current cigarette smoker?*

Q46

If yes, how many cigarettes or ecigs per day?

Q47

Do you drink caffeinated drinks?*

Q48

If yes, what and how many per day?

Q49

Do you drink alcohol?*

Q50

If yes, how many glasses per day?

Q51

Do you have any pain or issues in your:*

Q52

If yes, please explain.

Q53

Are you on any specific food/diet plan at this time?*

Q54

Have you had any recent weight gain or loss?*

Q55

If yes, please explain:

Q56

Please list any dietary supplements you take here (protein powder, creatine, B12, etc). Enter none if none.*

Q57

Please list any allergies you have here. Enter none if none.*

Q58

Please rate how you feel your current nutritional habits are*

Q59

Is there any reason not mentioned why you should not follow a regular exercise program? (Please remember it is your responsibility to you to consult with a physician before starting an exercise routine)*

Q60

Which of the following goals best fit in with your goals for your training (select all that apply)?*

Q61

What are the top three goals you want to accomplish, in order of importance?*

Q62

Explain why these three goals are most important to you.*

Q63

What possible personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?*

Q64

How often are you willing to train per week to reach goals?*

Q65

Do you have a membership at a commercial gym?*

Q66

If yes, what gym?

Q67

What equipment do you have access to at home?

Q68

Do you currently exercise on a regular basis?*

Q69

If yes, how many days a week?

Q70

How long is each session in minutes?

Q71

Describe your exercise routine:

Q72

Do you currently participate in any competitive sports?*

Q73

If yes, what sports and how often?

Q74

Have you trained with a personal trainer before?*

Q75

If yes, was your previous experience negative or positive? Why?

Q76

Describe what you expect of me as your fitness coach.*

Q77

Please rate your mental readiness to make changes to reach your goal.*

Q78

Please rate your motivational level to do what it takes to reach your goal.*

Q79

What motivates you?

Q80

Can you accept responsibility for the way your body is today and understand that, while your old habits don't make you a bad person, they still need to be changed?

Q81

I agree to the above terms and conditions!*

Q82

Client Signature*

Q84

Personal Trainer Intake -Form Fill

Full Name*

Full Name*

Gender*

Date of Birth*

Date of Birth*

Date of Birth*

Age*

Height*

Weight*

Address*

Address*

Address*

Address*

Address*

Phone Number*

Email*

What is the best way to contact you?*

What do you do for a living?*

What is the activity level at your job?*

Do you follow a regular working schedule, do you work days, afternoon or nights?*

How often do you travel?*

How would you rate the stress of your job?*

How would you rate the stress of your lifestyle?*

What are your hobbies, or what do you like to do in your spare time?*

Has your doctor ever said you have a heart condition?*

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?*

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

If yes to the above question, please list the condition(s) here.

Are you currently taking prescribed medications for a chronic medical condition?*

If yes to the previous question, please list your medications and how long you have been taking them.

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?*

If yes to the above question, please explain the condition.

Has your doctor ever said you should only do medically supervised physical activity*

Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?*

If Yes to the question above, please list reason here.

If you are on any medications not previously mentioned, including multivitamins,please list them here, including how long you have been taking them. Enter none if none.*

If you have any diagnosed health problems not previously mentioned, please list the condition(s) here. Enter none if none.*

Please list any injuries or surgeries you have had in the past five years. Enter none if none.*

Has anyone of your immediate family developed heart disease before the age of 60?*

Do any diseases run in your family?*

If yes to the above question, please explain.

Do you suffer from or have a history of:*

If yes to any of the above, please explain here.

Are you a current cigarette smoker?*

If yes, how many cigarettes or ecigs per day?

Do you drink caffeinated drinks?*

If yes, what and how many per day?

Do you drink alcohol?*

If yes, how many glasses per day?

Do you have any pain or issues in your:*

If yes, please explain.

Are you on any specific food/diet plan at this time?*

Have you had any recent weight gain or loss?*

If yes, please explain:

Please list any dietary supplements you take here (protein powder, creatine, B12, etc). Enter none if none.*

Please list any allergies you have here. Enter none if none.*

Please rate how you feel your current nutritional habits are*

Is there any reason not mentioned why you should not follow a regular exercise program? (Please remember it is your responsibility to you to consult with a physician before starting an exercise routine)*

Which of the following goals best fit in with your goals for your training (select all that apply)?*

What are the top three goals you want to accomplish, in order of importance?*

Explain why these three goals are most important to you.*

What possible personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?*

How often are you willing to train per week to reach goals?*

Do you have a membership at a commercial gym?*

If yes, what gym?

What equipment do you have access to at home?

Do you currently exercise on a regular basis?*

If yes, how many days a week?

How long is each session in minutes?

Describe your exercise routine:

Do you currently participate in any competitive sports?*

If yes, what sports and how often?

Have you trained with a personal trainer before?*

If yes, was your previous experience negative or positive? Why?

Describe what you expect of me as your fitness coach.*

Please rate your mental readiness to make changes to reach your goal.*

Please rate your motivational level to do what it takes to reach your goal.*

What motivates you?