PT Assessment Form

Name: Date (mm/dd/yy):

D.O.B (mm/dd/yy): Gender: Telephone:

Email:

What are your fitness goal(s)?

What is your current weight? Do you smoke?

Do you drink? Do you drink soda / energy drinks?

Do you drink coffee? Are you currently doing any type of exercise?

Have you ever participated in the training program?

Have you ever worked with a Nutritionist or Certified Personal Trainer?

How would you rate your motivation towards training (5 being the highest)?

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

What is the timeframe to reach your fitness goal?