Personal Trainer Request

PERSONAL INFORMATION

Last Name
First Name
Address
City
State
Zip Code
email address
Telephone (day)
Telephone (evening)
Telephone (cell)
Occupation

Birthdate Age Height Weight

Gender

Male

Female

Days and Time Available for Training	Monday	Time
	Tuesday	Time
	Wednesday	Time
	Thursday	Time
	Friday	Time
	Saturday	Time
	Sunday	Time

EMERGENCY INFORMATION

Emergency Contact
Telephone
Relationship

Your fitness Trainer wants to provide the highest quality service possible. The following will be used to design your fitness program.

1 GOAL SETTING
Tell us about your fitness goals (please check all that apply:

Body Fat/Weight Loss	Strength	Body Building
General Health	Nutrition	Energy
Core	Balance/Agility	Muscle Gain/Hypertrophy
Flexibility	Body Sculpting/Toning	Sports Performance
Other		Endurance Training

2 MEDICAL and HEALTH HISTORY
These conditions affect your ability to exercise, please check all that apply to you.

Arthritis	Asthma, Emphysema, Bronchitis
Back Pain	High Blood Pressure
Knee or Other Joint Pain	Coronary Disease
Shin Splints	Heart Disease
Foot Pain	Any known Heart Problems
Muscle Pain	Stroke
Other Pain	Epilepsy
Light Headedness/Fainting	Diabetic
Chest Pain at rest or exertion	Hypoglycemia
Shortness of Breath	Pregnant
Hernia	Family History of Coronary Disease before 55
Cigarette smoking or tobacco use	History of Atheroselerotic Disease before 55
Elevated Triglyceride Levels
Elevated Cholesterol Levels
Surgeries, Hospitalization-Specify:
Broken Bones-Specify:

Other Medical Conditions, Medications, Additional Info:

3 FITNESS AND ACTIVITY PROFILE
How much time are you willing to dedicate to an exercise program? Days/Week Hours/Day
What physical activities do you participate in on a regular basis?
What have you done previously to accomplish your goals?
Do you reguarly eat 3 meals a day? Yes No
If not, which meals do you skip?
How many glasses of water do you drink per day? glasses/day