| Name:
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E-mail:
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| Year of Birth: |
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| Telephone: |
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| General Questions: |
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To help me better understand your needs, please take a few minutes to answer the following questions:
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| Do you have any injury or condition, past or present that may affect your ability to do an exercise program? |
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| If yes, please explain: |
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| What is your current level of satisfaction with your exercise routine? |
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| Have you ever worked with a personal professional trainer? |
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| If yes, please describe your experience: |
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| How difficult do you find it to achieve your fitness objectives? |
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| What gets in the way? Please check all that apply. |
Lack of Knowledge
No follow-through
Lack of Commitment
Keep making excuses
I think I'm doing everything right, but it's not working
Intimidated by the gym atmosphere
I made progress at first, but now I am stuck
Other, please explain
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| What dissatisfaction do you have with the gym where you belong now? |
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| Are you concerned about the risk of osteoporosis and other diseases related to inactivity and age? |
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| If yes, what are you currently doing? |
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| Indicated the type and amount of activities you do regularly (check all that apply): |
Walking Slow (20 minutes a mile)
Walking Fast (15 minutes a mile)
Jogging (10 minutes a mile)
Running (8 minutes a mile)
Leisure Cycling (6 mph)
Cycling Fast (12 mph)
Leisure Swimming
Racquet Sports
Calisthenics
Aerobics
Basketball and/or Football
Soccer or Similar Sport
Weight Training
Golf or Bowling
Downhill Skiing
Cross-Country Skiing
Water Skiing
Other
None
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| Average number of exercise sessions per week |
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| Average duration of each session |
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| On a scale of 1 to 5, on the average how hard do you work out (1=very light, 5=very hard)? |
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| What are your fitness goals? |
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| Additional information you feel is important for me to know when assessing your fitness goals: |
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Enter the number shown above |
Thank You! |
