Placement
Personal Training
Personal Training – Client Applications
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Client History Form
Trainer
*
Trainer's Email Address
*
First Name
*
Last Name
*
Email
*
Date
*
Date of Birth
*
Age
Weight (lbs)
*
lbs
Goal weight (lbs)
*
lbs
Current body composition
%
Primary Goal
*
Weight loss
Physique competition
Muscle building
Applicant Testing
Athletic Performance
Health improvements
Other
Please specify
*
Triathlon
Distance running
Martial arts
Track
Swimming
Rowing
Hockey
Cycling
Other
If other, please specify
Expected time to reach goal
*
weeks
Target Competition Date
*
Desired Category
*
Bodybuilding
Physique
Figure
Fitness Model
Bikini
Exercise equipment available to client
*
Fitness classes
Home workouts
Outdoor cardio (i.e. run or bike)
Commercial gym
Crossfit
Has client previously tried to reach goal?
*
Yes
No
Please elaborate on the efforts
Please also indicate any reasons for why you may not have been successful with prior attempts
Is client currently following a fitness program?
*
Yes
No
Please describe current workout routine
What is typical/preferred time to workout?
*
Early morning (before breakfast)
Mid morning
Lunch/mid-day
Afternoon
Evening/after work
Night time
Who does client work out with?
*
Solo
Workout buddy
Personal Trainer
Small group
Sports team
Fitness class
How long are workouts?
*
< 20 minutes
20 - 40 minutes
40 - 60 minutes
60 - 90 minutes
> 90 minutes
Ideal # workouts/week?
*
2
3
4
5 or more
Weight training experience
*
None
0 - 6 month
6 - 12 months
1 -3 years
> 3 years
Rate comfort level with the following lifts
1 = novice; 5 = expert
Barbell squat
1
2
3
4
5
Deadlift
1
2
3
4
5
Bench press
1
2
3
4
5
Chin up/pull up
1
2
3
4
5
Power clean
1
2
3
4
5
Date of last physical exam/physician's visit
Does client suffer from any of the following?
Arthritis
Ankle pain
Carpal tunnel/wrist pain
Unspecified chronic pain
Herniated disks
Hip pain
Knee pain
Low back pain
Rotator cuff injury
Has client ever been diagnosed with any of the following?
Ashtma
Atherosclerosis
Cancer
Diabetes
Epilepsy
Gastrointestinal disorders
Gout
Heart disease
High cholesterol
Hypertension
Osteoporosis
Stroke
Thyroid dysfunction
For all issues checked, please elaborate
List all medications or herbal supplements/vitamins (and dosages) currently used
List all allergies (environmental, drug and food based)
Does client smoke?
*
Yes
No
Packs per week?
packs
Do you consume canabis?
*
Yes
No
Times per week?
packs
Does client drink alcohol?
*
Yes
No
How many drinks per week?
Does client do shift work?
*
Yes
No
If yes, please elaborate on work hours
Additional comments
If there is any other information you'd like to communicate to your trainer, please indicate it above.
If you are human, leave this field blank.
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