| Name: |
| Phone Number: |
| Email: |
| MaleFemale |
STEP 1: Goal |
| What is the single most important goal for you to achieve with your exercise program? | |
| What outcomes are you looking to experience as a result of your exercise program? | |
| In what time frame do you expect to achieve your goals? | |
| Aside from your time at the gym, how much additional time per day are you willing to engage in activity that helps you get to your goal – such as daily walks, using the stairs, or home exercise? | |
| Are all aspects of your workouts completely up to you or is someone or something else a consideration when designing your program variables? (your obstacles) | |
| Do you have any present or past injuries? Do they still bother you in any way? | |
| Do you have any medical history I need to know about? Do you take any medications? | |
| How many days a week do you plan on working out? | |
| What equipment do you have access to? | |
STEP 2: Style |
| Is it more important for you to feel continually challenged or to feel structured during your workouts? | |
| When you need to reduce stress do you ideally enjoy activities that are exciting, adventurous and give you a chance to blow off steam, or activities that are practical and relaxing? | |
| Do you enjoy exercise more when it involves a routine that you can adhere to or one that offers a variety? | |
| Are there any activities you don't like or want to avoid? | |
| Are there any activities that you enjoy or want to try? | |
| Does your occupation require extended periods of sitting? | YesNo |
| Does your occupation require repetitive movements? | YesNo |
| Does your occupation cause you anxiety or mental stress? | YesNo |
STEP 3: Level |
| Would you say that your work is active, sedentary or physically strenuous? | |
| What is your occupation? | |
| What hobbies do you enjoy? | |
| Do you regularly participate in recreational activities? Is that monthly, weekly, more or less frequent? | |
| Are you currently exercising? If yes, what type of exercise program are you currently participating in? | |
| What has prevented you from achieving your goals in the past? | |
| What is your experience with working out? | |
STEP 4: Motivation About Goal |
| Why is this goal most important to you? | |
| If you don't make these changes and stay the way you are or regress in your health and fitness, how would that affect your life? What consequences could occur? | |
| When you do successfully reach your goal, in what ways will life be different? | |
| What benefits are most important to you? | |
| On a scale from 1-10 how important is it for you to make those changes right now? | |
| Why is it not a 2 or 3? | |
| What would make it a number higher? | |
| Do you believe you can make these changes? | |
| On a scale from 1-10 how confident are you? | |
| What would make your confidence one number higher? | |
| Are you ready and willing to change at this time? | |
| In what ways do you believe I can help you? | |
