Name:

Address:

Phone:

Email:*

D.O.B.:

Height:

Weight:

BF%:

Are you interested in working with a personal trainer?
Yes

Do you prefer a Male or Female trainer?
M F

Available times to train:

List your Daily Meals:

List your weight training, weight gain/loss goals...

in 6 weeks:

in 3 months:

in 6 months:

List Supplements you have taken
or have heard about and may be interested in:

List any foods or substances
you may be allergic to or dislike:

Please describe your current workout schedule.

Sunday:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

List the tree most difficult aspects
of your dietary/weight training efforts:

Additional Information,
Concerns or Questions you may have: