PERSONAL TRAINING: CLIENT CONSULTATION FORM

First name

Last name

Phone

Date of Birth

Height

Weight

Emergency Contact

Emergency Contact Phone #

CURRENT LIFESTLE/ACTIVITY LEVEL *

Sedentary

Active

Physically Demanding

Tobacco Use: *

Yes

No

I currently work out ___ times per week

When I workout, I complete the following activities / additional details.

I typically eat ___ meals per day

When I eat/snack, the following are the types of foods/meals I eat on a regular basis.

GOALS: (check all that apply)

Improve cardiovascular fitness

Facilitate body-fat weight loss

Improve performace for a specific sport

Improve Flexibility

Reshape/tone body

Increase Strength

Improve mood + ability to cope with stress

Short Term Goals (3months or less)

Long Term Goals

Rank the following in order of Importance (1 being most important)

Weight Loss

Strength Gain

Muscle Gain

Mobility Improvement

Postural Improvement

PAST WORKOUT HISTORY

Positive Experiences

Negative Experiences/ Obstacles to Success

Activities/Movements/Exercises Enjoyed

Activities/Movements/Exercises Disliked

INJURIES/RESTRICTIONS

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