SLEEP

On average, how many hours do you invest in sleep each night?

In your opinion, this amount of sleep is...

How many days/wk do you usually wake before 6am?

How many days/wk do you usually stay up past 11pm?

On average, how long do you think it took you to fall asleep each night? Please Select 0-20 minutes 20+ minutes

Did you regularly wake up in the middle of the night? Please Select Yes No

You woke most days feeling? Please Select Tired Refreshed Average

MEDICAL QUESTIONS

What is your current weight?
(Enter 'NA' if not applicable)

In your opinion, are you physically fit enough to participate in an exercise regimen?

Have you been advised by a medical professional that you SHOULD NOT participate in an exercise regimen?

*Note: For the following questions, please put N/A if not applicable.

Health Problems?

Medications?

Injuries?

Chest Pain?

Diabetes, Asthma, BP?

DIET/NUTRITION

Your current diet could be best characterized as:

Please Select Low Fat Low Carb High Protein Vegetarian/Vegan No special diet

On average, approximately how many CALORIES/DAY are you currently consuming?
(Enter "No idea" if you have no idea)

On average, approximately how many GRAMS/DAY of each macronutrient are you consuming?
(Enter "0" if you have no idea)
     

How would describe your appetite this past week?

Have you ever tracked your diet (calories and macronutrients) or kept a food journal before?

Are you willing to track your diet (calories and macronutrients)?

On a scale of 1-5, how would you rate your willingness to change your diet?

On a scale of 1-5, how would you rate your Nutrition

On average, how much CAFFEINE/day did you consume this past week?
(6oz Coffee = 85mg | 8.4oz Redbull = 125mg | 16oz Bang/Reign Energy Drink = 300mg)

On average, how much WATER/day did you consume this past week?
(1 gal = 128oz | 1/2 gal = 64oz | 1 pint = 16oz | 1 cup = 8oz | N/A = don't track)

BIOMARKERS

Did you experience any digestion issues?

Examples:
• Acid Reflux/Heartburn
• Halitosis/Bad Breath
• Upset Stomach/Diarrhea
• Urgent Bowel Movement [post meal]
• Abdominal Bloating, Pain, Cramps, or Gas
• Hungry Shortly After Meals
• Constipation/Hard Bowel Movements
• Vomiting/Nausea

Please Select Yes No

Did you experience any of the following post-workout biomarkers...

• Non-specific Soreness [i.e. Joint Pain, Non-muscle Soreness, Etc.]?
• Excessive local muscle soreness (3+ days)?
• Hard time focusing during the day?
• Loss of appetite?
• Irritability/Mood Swings?

Please Select Yes No

Are you currently experience any of the following during your workouts...

• Loss of 'pump' during an exercise?
• Performance decline later in the workouts?
• Weight feeling heavier than it should?

Please Select Yes No

SUPPLEMENT QUESTIONS

Please list any nutritional supplements you are currently taking.

Are you open to taking supplements if they will help you achieve you goals?

Adverse Reaction to Supplements?

TRAINING HISTORY

*Note: For the following questions, please put N/A if not applicable.

Exercise History

Current Exercise

Any lagging/underdeveloped muscle groups that you would like to focus on?

Any specific exercises you would like to improve?
(i.e. Squats? Deadlifts? Bench? Clean & Jerk?)

Ideally, how many days/week would you like to train?
Please Select 1 2 3 4 5 6 7

Which days of the week would you like to train on?

How much time can you dedicated to exercise per training day
(Alternatively, what is your ideal amount of workout time/session?)

Are you familiar with lifting nomenclature?
(Do you understand the following terms: Reps, Sets, Rest Interval, Tempo, RIR, RPE, Eccentric, Concentric, Sets to Failure, Load, Intensity.)
Please Select Yes, All Most, >50% Few, <50%

GOAL SETTING

How can a Personal Trainer help you? Please check all that that apply.

In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure all your goals are ‘SMART’.

• S= Specific
  (Provide details, how long, how much etc.)
• M= Measurable
  (How will you measure whether you’ve reached your goals)
• A= Attainable
  (Be realistic, set smaller goals)
• R = Rewards-Based
  (Attach a reward to each goal)
• T = Time Frame
  (Set specific dates for goals)

Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months?

On a scale of 1-5, how would you rate your commitment to achieving your goals?

On a scale of 1-5, how would you rate health as a priority in your life?

What do you think the most important thing we can do to help you achieve your fitness goals?

What will change when you achieve that goal?

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals.
(i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise etc.)

LIABILITY WAIVER For insurance purposes, ALL trainees must sign our liability waiver. I have READ and AGREE to GYM NUMBER FIVE's Release and Terms of Agreement. Electronic Signature (Legal Guardian if Under 18) I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. Today's Date

Please Verify You Are Human :-)

Thank you!