Date of Birth
Part 1: Exercise History and Interests
On average, how many times do you exercise per week?
On average, how long do you exercise per session? In Minutes...........................
On a scale from 1 to 10, how intense is your typical workout? (check one)
Part 2: Goals You Want to Accomplish
Check all that apply, no one but you and your trainer will be able to see what u checked off.
What is your exercise history?
What health improvements do you need?
What other health improvements do you want?
What are your activity preferences?
How will you know you are succeeding?
What is your motivation level? High Medium Low
What is your confidence level? High Medium Low
Part 3- My Commitment
Please use the space below to record three concrete commitments that you are willing to make to your own health goals. For example you might commit ”To arrive, ready for exercise, on Mondays, Wednesdays and Fridays by 6:30pm“. These should be challenging but also realistic and attainable commitments. When finished, please submit this form to signify your personal commitment (this is not a law abiding contract just a contract with yourself)