Name: First Last Email: Address: Address Cell Phone:Age: Sex: Weight: Height: Occupation: 1. Please give a brief list of your goals or what you want to accomplish. This could range from strength and conditioning to toning and nutrition:2. Motivation: What is driving you to make a lifestyle change?3. Are you currently taking any medications? If so, please list:4. Please list any illnesses, injuries or nagging aches and pains you are currently experiencing:5. Do you currently exercise? If so, what do you do and how often (please be as specific as possible, ex: strength training in the gym 3x/wk, running out doors 2x/wk):6. Do you have access to a gym? If so, what kind (name of gym or if it’s an apartment complex):7. If you have gym access or have had it in the past, how would you rate your comfort level with gym equipment and various exercises: 1= very uncomfortable, little to no experience with strength training; 10= extremely confident in the gym, it’s my 2nd home (please provide me with a bit of your experience):8. If you don’t have access to a gym, what home equipment do you have? (Dumbbells, exercise balls, jump rope, etc.)9. If you do not have access to a gym, are you willing to purchase some items to create your own home gym? (dumbbells, jump rope, resistance bands)10. What time do you typically wake up and go to bed?11. Realistically, how many days per week can you dedicate to the gym or home training program?12. How many minutes per day can you dedicate to each training session?13. What type of physical activity do you enjoy?14. Please list any favorite routines, exercises you prefer performing, and/or a specific body part or physique you would like to improve/achieve:15. What time of day do you prefer to do weight training?
