Phone Number

    Email Address

    Current Weight

    How Long at Weight


    Describe your current fitness routine

    Describe what you would like to accomplish through your fitness program with me

    Aside from technical knowledge and personal attention, what type of motivation do you require and expect from a trainer?

    What can we do together to make your exercise program more enjoyable?

    What type of exercise interests you? (Check all that apply)

    Walking (treadmill/outdoors)Running (treadmill / outdoors)HikingSwimmingTennisCyclingStationary BikeStrength TrainingYogaStretchingPilatesDance Exercise

    Describe what/where you workout and what you have available to you for equipment?

    Rate the importance of these goals on a scale of 1 to 10
    1 being not at all important and 10 being extremely important

    Improve cardiovascular fitness

    Body-fat weight loss

    Reshape or tone my body

    Build more muscle

    Improve flexibility

    Increase Strength

    Increase energy level

    Improve performance for a specific sport

    Improve mood and ability to cope with stress

    Feel better/improved health


    Anything else I should know about you?