Personal Training Questionnaire Name First Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhonePhysicians Name Physician's PhoneEmail Gender Male Female Weight Height How did you hear about EricLeija.com Did someone refer you? Fitness HistoryHave you been exercising consistently for 3 months or more? Yes No How long have you been exercising? When were you in your best shape? When did you decide to get in shape? Have you completed an exercise program in the past? If so was it with a personal trainer? If so did you achieve positive results? What, if anything stopped you from continuing your exercise program? How can you improve from past experiences? Current Program / Program DevelopmentHow would you rate your current fitness experience level?UntrainedNoviceIntermediateAdvancedEliteHow much / how often do you perform cardio? How much / how often do you weight train? List any other cardio / sports / activities you are involved in:Please explain your expectations and goals you would like to reach through this program:Why have you chosen to hire a personal trainer? Realistically, how often are you willing to exercise? How much time are you willing / capable of spending in each exercise session? Explain in detail the programs that interest you, what you like / dislike, and anything related to your current program:Do you have any injuries? Please list past injuries even if you think them unimportant: Do you have any specific exercises that you are unable to perform? If so please list them: Explain in detail and obstacle (behaviors, stress, activities, etc.) that you foresee impeding your success:Have you developed any plans to overcome these obstacles? Nutritional InformationHow do you monitor your eating habits? Do you feel that you typically maintain a healthy diet? How much water do you typically drink in a day? Describe your daily diet:How do you feel about structured diets, and have you tried any in the past?What does the term diet mean to you? Additional InformationPlease describe your typical day from morning to evening:Please list and explain any additional information you feel is important to your personal training experience:Upload before photos for future reference: Drop files here or Select files Max. file size: 64 MB, Max. files: 3.