ONLINE CONSULTATION

Full name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Preferred method of contact? *

Email Phone call Text

Age? *

Your current weight? *

Your sex? *

Male Female Other

Your height? *

Job Role? *

Details of your journey to work? *

Work start/finish time? *

How much sleep do you get per day? *

Stress level? *

5 stars - very stressed

Are you currently a member of PureGym Barrow Road Bristol? *

Yes No

PLEASE NOTE: An active day pass or membership is required at PureGym Barrow Road Bristol for face to face personal training. It is not required for online training services.

How many days per week do you order takeaway? *

How many days per week do you drink alcohol? *

Do you snack or pick at food throughout the day? *

What is your 'go to' comfort food & how often would you eat it in the week? *

Are you currently tracking calories? *

How many days per week are you physically active? *

On average what is your daily step count? *

When are you most productive? *

Morning Mid-Morning Afternoon Evening

Please state any injuries within the last 12 months along with any medication you may be using. *

Do you know any reason why you cannot partake in physical activity? *

Do you smoke? *

Yes No Social smoker

FEMALE ONLY: Please detail information relating to menstrual cycle length, frequency or if you are postmenopausal: *

Do you have support towards your fitness goals from friends, family etc? *

Please state in as much detail as possible

What do you feel you need from me as a trainer to accomplish your goals? *

What is the biggest obstacle preventing you from achieving your goals? *

Do you have any holidays booked/time away within the next 3 Months that may effect the outcome of your results? *

What or who inspires you to change? *

What area of fitness are you looking for? *

If other please state below

What has worked well for you in the past and why are you not doing it now? *

In detail what are you hoping to achieve through personal training? *

What is your main area of weakness? This could be food or exercise related. *

What is your commitment to change? *

5 stars - very commited

How motivated are you? *

5 stars - very motivated

Have you ever had a Personal Trainer before? *

If yes, please state all details

Have you previously sought dietary advice? (If so, please expand) *

Do you own digital bathroom scales? *

Do you own digital kitchen scales?

How many times per week would you like personal training? *

The different services I offer vary in terms of the level of support, time and client effort required. To better help advise you on the most appropriate and effective service for your individual goals, please indicate the Monthly budget most applicable to your current situation. *

Do you know someone who may be interested in training with you? *

If yes, please provide details below.

Name of friend

First Name Last Name

Phone Number of friend

Area Code Phone Number

Email of friend

example@example.com

How did you hear about Empower Strength & Nutrition? *

Would you be willing to provide a testimonial and/or before and after photos (if applicable) for the Empower Strength & Nutrition website? *

Please note that all information provided is strictly confidential between Empower Strength & Nutrition and yourself. Your information will not be shared with any other organisation or third party. If you have any concerns please email Andrew Davies direct at - andrewdaviespt@hotmail.com.

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By clicking this button, you submit your information to Empower Strength & Nutrition, who will use it to communicate with you regarding this form and their other services. *

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