Questionnaire – refresh browser first

Your Name*
Email*
Date of Birth
Address
City
State
Zip Code
Phone
Fax
Height
Weight
Gender
- Male
- Female
Body Type
- Thin
- Medium
- Stocky
Body Shape
- Athletic
- Apple
- Spare tire only
Today's Date
Purchasing (check one or more)
- Online personal training / coaching
- Personal training
- In home yoga, Pilates, boxing
- Consultation
1. Do you have any health condition that would put you at risk while following a strict diet or exercise program (such as diabetes, high blood pressure, heart condition, pregnancy , etc.)?
- Yes
- No
If yes, please name condition(s):
2. Do you have any injuries, past or present, which could possibly impact your ability to exercise?
- Yes
- No
3. What do you want the product of your training to be (ex.: a beautiful physique, greater health and vitality, etc.)?
3. What do you want the product of your training to be (ex.: a beautiful physique, greater health and vitality, etc.)?
Why?
4. On a scale of 1 to 10 , rate your commitment to the goal of achieving the body of your dreams:
5. Last regular exercise was (how many) months ago.
How often?
What do / did you do?
6. What is the amount of time in days and hours that you are willing to commit to physical training?:
7. How often do you normally involve yourself in aerobic activity?
8. What is your favorite form of aerobic activity:
9. How often do you train with weights and for how long?
10. How many calories do you think you consume in a normal day?
11. How many meals do you eat in a normal day?
12. Do you feel hot or cold often?
- Yes
- No
13. Are your hands or feet cold often?
- Yes
- No
14. Do you itch or sneeze after eating fruit? If yes, what kind?
15. Are you lactose intolerant?
- Yes
- No
If yes, with what severity? Please describe
16. Do you suffer from poor digestion or gas?
- Yes
- No
If yes, when?
17. If you are ordering a workout program, please specify your goals
Gain muscle # pounds:
Lose fat # pounds:
Please add any special info about your goal you think I may need :
18. If you are ordering a nutritional program, Please list everything you have eaten for the past two days:
Yesterday
Day before
19. Do you commit to following the advice of your trainer completely?
- Yes
- No
20. What time do you wake up?
21. What time do you exercise?
22. What time do you go to sleep?
23. I will be training.
- At home
- At a gym
If at home, what exercise equipment do you have? (You can email me photos too)
24. The above information is accurate and complete to the best of my knowledge and belief.
- Yes
- No
Please send a "before" photo attached to a separate email to: [email protected]

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(310) 772-5105 (424) 235-0284 [email protected] Find Us Los Angeles Personal Training 12424 Wilshire Blvd #101, Los Angeles, CA 90025, USA

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