Personal Training Intake Form

Personal Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Alternate Phone

(###)

###

####

Fitness History

When were you in the best shape of your life?

Have you been exercising consistently for the past 3 months?

When did you first start thinking about getting in shape?

What, if anything, stopped you in the past?

On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?

Nutrition Information

On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?

How many times a day do you usually eat (including snacks)?

Do you skip meals?

Do you eat breakfast?

Do you eat late at night?

Note if sometimes, often, rarely, etc.

What activities do you engage in while eating? (TV, reading etc)

How many glasses of water do you consume daily?

Do you feel drops in your energy levels throughout the day? If yes, when?

Do you know how many calories you eat per day? If yes, how many?

Do you take a multivitamin or any other food supplements?

If yes, please list

At work or school, do you usually eat out or bring food?

How many times per week do you eat out?

Do you do your own grocery shopping?

Do you do your own cooking?

Aside from hunger, are there any other reasons you eat?

Examples: Boredom, stress, depression, happiness, nervousness, social situations, etc

Do you ever eat past the point of fullness?

Do you eat foods high in fat and sugar?

List three areas you'd like to improve your nutrition.

Are you interested in nutrition assistance from a professional coach?

Exercise Information

How many times per week do you exercise?

If you exercise less than you'd like, what are the reasons?

For how long have you been consistently physically active?

What physical activities do you currently do?

Include cardio, strength training, stretching, and any sports or physical activities you participate in

What physical activities do you not currently do that you might be interested in taking up?

Realistically, how many times per week would you like to exercise?

Do you prefer to exercise alone or in a group?

What time of day do you prefer to exercise?

Realistically, how much time do you wish to spend per exercise session?

Where do you prefer to exercise?

Ie, at home, at a gym, at a park, etc.

How often do you want to work with a trainer to meet your exercise goals?

3x/week 2x/week Weekly Every other week Monthly

Please list the top 3 fitness goals you'd like to achieve over the next year.

Hays Recreation Commission · 1105 Canterbury Drive, Hays, KS 67601 · 785-623-2650

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FORM - Personal Training Intake

Personal Training Intake Form