Name *
E-mail Address *

Telephone: *

Date of Birth:

Gender: Male Female
Have you worked with a personal trainer before? Yes No
Do you exercise at Home or in a Gym/Health Club? HomeGym Health Club

Do you have any health conditions or injuries? Please list any.

Do you currently do any exercise and if so, how often?
1 day/week 2 day/week 3 day/week 4 day/week 5 day/week
6 day/week 7 day/week No exercise

Considering your age, how would you consider your overall health?
Excellent Good Fair Poor

On a scale of 1 - 10 (with 10 being the most enthusiastic)
how motivated would you say you were to exercise? 1 2 3 4 5 6 7 8 9 10

Please indicate your personal health and fitness goals (check all that apply):

• Lose Fat Improve Flexibility Reduce Stress Lower Risk of Disease
  
• Stop Smoking Rehab Injury Improve Cardiovascular Fitness
• Gain Muscle Size Increase Muscle Strength
• Improve Sports Performance
• Enhance Health Reduce Pain Improve Diet

Please check the box that best describes your work and exercise habits:

• Intense occupational and recreational exertion
  
• Moderate occupational and recreational exertion
  
• Sedentary work and Intense recreational exertion
  
• Sedentary work and moderate recreational exertion
  
• Sedentary work and light recreational exertion
• Complete lack of all exertion

Additional questions or comments? Please type them in the box below.