Program Request

What is the activity level?
not activeModerate (light activity such as walking)Active (physical job or exercising)

Do you work:
DaysAfternoonsNightsShift Work

How often do you travel?
RarelyA few times a yearA few times a monthWeekly

List your physical activities outside of the gym and work:

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the diagnosed health problem(s)?

If you have any injuries, please list them:

What additional therapies are being undertaken for the given injury?

Do you suffer from diabetes, asthma, high or low blood pressure?
YesNo
if yes please list which one:

Are you a smoker?
YesNo

Your current diet could be best characterized as:
low-fatlow-carbhigh-proteinvegetarian/veganNo special dietOther

Do you have any food allergies or specific foods that you don't eat?

What are your main food preferences?

What following goals best fit in with your goals?Weight lossIncreased muscle massIncreased muscle toneIncreased strengthHealth benefitsImproved mobility

What is your goal with your training?

Why?

Timeline for achieving your goal:

How often are you willing to train to reach your goal? (days per week)
1234567

Please rate your motivational level to do what it takes to reach your goal
12345678910

Are you currently exercising regularly (at least 3x per week)?
YesNo

Would you go to the gym for your workouts or will you exercise from home or any other venue?
GymHome/other

If not going to the gym, what equipment would you have access to?