PT Assessment Form

Name: Date (mm/dd/yy):

D.O.B (mm/dd/yy): Gender: —Please choose an option—MaleFemale Telephone:

Email:

What are your fitness goal(s)?

What is your current weight? Do you smoke? —Please choose an option—YesNo

Do you drink? —Please choose an option—YesNo Do you drink soda / energy drinks? —Please choose an option—YesNo

Do you drink coffee? —Please choose an option—YesNo Are you currently doing any type of exercise? —Please choose an option—YesNo

Have you ever participated in the training program? —Please choose an option—YesNo

Have you ever worked with a Nutritionist or Certified Personal Trainer? —Please choose an option—YesNo

How would you rate your motivation towards training (5 being the highest)? —Please choose an option—12345

Realistically, how many days are you available to exercise per week?

What is the timeframe to reach your fitness goal?