Fitness Consultation Form

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Name

Date of Birth

Email

Phone

Preferred Calling Method
Telephone
Video

What does being healthy and well mean to you?

In Priority, list the fitness goals you would like to achieve in the next 3 to 12 months. Some examples are listed below.
Develop Muscle Tone / Increase My Energy Level/Lose Body Fat / Increase my Cardiovascular Ability / Become More Motivated / Start A Routine Exercise Regimen / Rehabilitate an Injury / Lift or Push a Specific Weight Amount / Create a Healthier Lifestyle /Loose Pounds / Gain More Confidence / Understand Exercise Better / Become More Flexibility / Create Your Own

When did you first start thinking about becoming healthier and more fit?

What would you rate your current physical activity/ exercise routine? Check one.
0 - Basically None
1 - Little, physical activity
2 - I have waves of physical activity but not very consistent
3 - Fairly consistent at participating in some type of physical activity on a regular basis
4 - Maintaining physical activity has been a priority of mine and for most of the time I’ve done a decent job keeping up with it
5 - Physical activity is a consistent and important part of my life, I am just trying to take it to the next level)

How long have you been exercising regularly?

Month(s)

Year(s)

If you have any previous experience working out briefly explain. Ex. what type, how long ago, and how long did you participate?

What has stopped you in the past from exercising on a regular basis or dieting?

What do you feel causes you to struggle the most when it comes to achieving your goals?
Examples: Lack of discipline, Time management, It has been too hard, Lack of understanding/planning, Needing help with accountability, Never tried, Don’t know how to start/Became distracted by life’s struggles/ Not sure

What hobbies do you enjoy?

How do you feel about your life most of the time?
0 - I feel very depressed and hopeless
1 - I am usually sad and lonely
2 - I struggle with my emotions, but still have the ability to see the good in life
3 - I have hard days where its difficult to uplift myself, but I also have just as many days when I feel good about life
4 - Though my life can be hard I feel good about my life
5 - I love my life and am ready to take on its highs and lows

What time do you typically go to sleep on an average night? What time do you typically wake up?

List any special requests, considerations, training style, exercise, or equipment preferences?

On a scale of 1-5, rate your eating habits
1 - Poor, no consideration or understanding on importance of healthy eating
2 - I think about it and have moments of trying but it doesn’t last very long
3 - Average, I try to make healthy eating decision atleast half the time, some weeks are better and/or worse than others
4 - I think eating healthy is important and overall maintain a balanced healthy diet
5 - Eating healthy is very important to me and I spend time, energy, and money prioritizing this in my life.

Do you want any help/ motivation in the area of trying to eat healthier at this time?

If so, what is the most intimidating or challenging aspect when it comes to eating a healthier diet on a regular basis?

How many minutes per day are you willing to devote to a fitness program?

How many days per week are you willing to devote to a fitness program?

Can you exercise during your work day?

Would an exercise program benefit you at your job?

If applies, how much would you like to change your current weight?

(-) lbs.

(+) lbs.

Where will you be exercising/working out?
Ex. Home, you have a gym membership, you’re not sure.

Let's Keep In Touch.

757-635-5910