Personal Fitness & Nutrition Development Questionnaire
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Date Received
Personal Fitness & Nutrition Development Questionnaire
Please complete the below application and submit to the C&RC Control Desk. The application will be reviewed by the
C&RC Fitness Staff and a Personal Trainer, which best suits your needs, will be selected and will contact you to schedule
a Fitness Assessment.
First Name: ____________________________________ Last Name: __________________________________________________
Phone Number: _________________________________ E-mail: _____________________________________________________
Address: ______________________________________
City/State/Zip: _______________________________________________
Age: ________________
Gender: _______________
Emergency Contact: __________________________________________
What are your Fitness & Nutrition goals? (Check top 3 most important goals)
Learn to eat a Balanced Diet
Decrease Body Fat
Tone Muscles
Learn to Balance Activity & Diet
Reduce Stress
Increase Strength & Power
Create a Healthy Lifestyle
Feel Better
Improve Speed/Agility
Improve Overall Health
Increase Flexibility
Improve Athletic Performance
Maintain a Healthy Weight
Increase Endurance
Other: _______________________________________
What is keeping you from achieving your Fitness & Nutrition goals? (Check all that apply)
Lack of Motivation
Time
Lack of Equipment
Hitting a Plateau
Self Conscious
Not Knowing Where/How to Begin
Money
Lack of Results
Other: ________________________________________
What motivates you? (Check all that apply)
Seeing Results
Having Fun
Praise/Rewards
Accountability
Feeling Better
Other: _________________________________________
Do you follow a current exercise regime?
Yes
No
If yes, please explain.
Are there any physical limitations that would inhibit or limit your participation in an exercise program?
Have you ever done personal training before?
Yes
No:
If yes, please Explain: (How long ago? Was your experience beneficial?)
What do you expect from a personal trainer?
Please list any other information your trainer may find useful in preparing a workout routine for you:
1551 Mayview Road
Upper St. Clair, PA 15241
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