Name
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First Name
Last Name
Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are currently suffering, or have you suffered any of the following? Please tick:About your health - 1.
If you have ticked any of the boxes above, please give details in the area below. If you've answered no to all the questions, please write none.
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Have you or any of your first degree relatives experienced any of the following conditions?
If you have ticked any of the boxes above, please give details in the area below. If you've answered no to all, please write 'None'.
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Have you ever had surgery?
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If yes, please give details in the area below, if no, please write 'none'.
Have you ever broken any bones?
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If yes, please give details in the area below. If no, please write 'None'.
Do you suffer from back pain?
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If yes, please give details in the area below. If no, please write 'None'.
Are you taking any medications that may affect or limit your ability to exercise, or affect your response to exercise? E.g. Blood pressure medication.
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If yes, please give details in the area below. If no, please write 'None'.
Do you have any other health conditions, injuries or pain that may affect or limit your ability to exercise?
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If yes, please give details in the area below. If no, please write 'None'.
How would you best describe your occupation?
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Please tick one box.
How would you best describe the quality of your sleep?
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Please tick one box
How many caffeinated beverages do you consume each day?
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Please tick one box. Include tea, coffee, cola and energy drinks.
Do you smoke, or have you given up in the last 6 months?
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If yes, indicate the number of cigarettes or cigars smoked each day. If no, please write 'No'.
How many units of alcohol do you consume each week?
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Please tick one box. 1 unit is usually a half pint of normal strength beer, a measure of spirits, or one small glass of wine.
How stressful is your life?
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Please tick one box.
How active are you each week?
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Include activities that elevate your heart rate and breathing e.g. brisk walking, cycling, swimming, heavy housework, DIY, gardening, gym, exercise classes
How would you best describe your current diet?
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Please tick one box
How much water do your drink each day?
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Please include water, still cordials, decaffeinated teas or coffee.
Which areas of your diet do you believe are excessive?
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If none, please write 'None' below:
Please give up to three goals you'd like to achieve with your programme of personal training:
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Goals can be quote general at this stage e.g. weight loss, improve fitness, get stronger, feel more energetic etc.
How much time can you devote to your exercise programme?
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On a scale of 1 to 10, how motivated are you to get started with a programme of exercise?
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Are there any other obstacles, other than those already detailed, that may hinder your efforts to become more physically active?
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If yes, please give details below. If none, please write 'None'.
Declaration
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Personal Training Booking Terms & Conditions
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Cancellation Policy: 24 Hours Notice of cancellation is required. Notice of less than 24 hours will mean the session is charged in full or will be deducted from your pre-paid package as if you had attended.
Lateness Policy: If you are late for a session, the session will not be extended and will end at the appointed time. If your trainer is late, additional time will be added to the session or subsequent sessions to make up for the lost time.
Refunds and package expiry: Pre-paid Personal Training packages must be used within 6 months from the date of purchase. Sessions will not be carried over or refunded that have not been used within this time.
