Name:
Email:
Age:
Phone Number:
Work Number:
Date of Birth:
Cell Number:
Fax Number:
Current Weight:
Mailing Address:
City:
Desired Weight:
Zip Code:
Height:
Interested in
Personal Training
Online Training
Super Group
Jr. Elite
Where did you hear about BodyTek?
Which cities/towns do you live and work in?
Do you perfer to workout at home or a gym?
Home
Gym
What time of day do you prefer to exercise?
Morning
Afternoon
Evening
Do you have any health problems that may impact your ability to exercise? If so, please describe. Please include current blood pressure if 140/90 or over.
Do you smoke?
Yes
No
Do you have high cholesterol?
Yes
No
Are there any areas of your body you are particularly stiff or sore? If so, where and to what degree?
What are your top three fitness goals?
Have you exercised in the past?
Yes
No
Are you exercising currently?
Yes
No
What does your current program consist of?
How effective has this program been for you?
Great
Ok
Not so good
What are the top 3 lifestyle, motivational, time constraints, and other challenges do you expect to encounter?
Have you had a personal trainer in the past?
Yes
No
If so, what was the experience like for you?
What expectations do you have of personal training?
Have you ever been on a diet in the past? If yes please explain.
Are you currently on any specific diet? If yes, please explain.
Are you currently on any medications? If so please explain.
Do you usually eat breakfast?
Yes
No
What types of foods do you enjoy most?
How many meals do you eat per day?
How many times per day do you eat snacks and what snacks do you normally eat?
What do you perceive as your top 3 dietary challenges?
I would like free weekly fitness and dieting tips sent to my email