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Your Name:

Email:

Date of Birth: [

Address:

City:

State:

Zip:

Phone:

Fax:

Height:

Weight:

Gender: MaleFemale

Body Type: ThinMediumStocky

Body Shape: AthleticApplePearSpare tire only

Today's Date:

Purchasing (check one or more):

Online personal trainingPersonal trainingIn home yoga, Pilates, boxingConsultation

1. Do you have any health condition that would put you at risk while following a strict diet or exercise program (such as diabetes, high blood pressure, heart condition, pregnancy , etc.)?
YesNo If yes, please name condition(s):

2. Do you have any injuries, past or present, which could possibly impact your ability to exercise?
YesNo If yes, please explain:

3. What do you want the product of your training to be (ex.: a beautiful physique, greater health and vitality, etc.)?
Why?

4. On a scale of 1 to 10 , rate your commitment to the goal of achieving the body of your dreams:

5. Last regular exercise was months ago. How often?
What do / did you do?

6. What is the amount of time in days and hours that you are willing to commit to physical training?:

7. How often do you normally involve yourself in aerobic activity?

8. What is your favorite form of aerobic activity:

9. How often do you train with weights and for how long?

10. How many calories do you think you consume in a normal day?

11. How many meals do you eat in a normal day?

12. Do you feel hot or cold often?
YesNo

13. Are your hands or feet cold often?
YesNo

14. Do you itch or sneeze after eating fruit? If yes, what kind?

15. Are you lactose intolerant?
YesNo If yes, with what severity? Please describe:

16. Do you suffer from poor digestion or gas?
YesNo If yes, when?

17. If you are ordering a workout program, please specify your goals :
Gain muscle # pounds: Lose fat # pounds: Please add any special info about your goal you think I may need :

18. If you are ordering a nutritional program, Please list everything you have eaten for the past two days:
Yesterday
Day before

19. Do you commit to following the advice of your trainer completely?
YesNo

20. What time do you wake up?

21. What time do you exercise?

22. What time do you go to sleep?

23. The above information is accurate and complete to the best of my knowledge and belief.
YesNo

Please send a "before" photo attached to a separate email to: jasonk@jasonkozma.com