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ESTEBAN RAMIREZ —
REVITALIZE
FITNESS HUB
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First name
Last name
Email
Phone
DOB
Month
Day
Year
Trainer
Preferred method of communication
E-mail
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Text
Purpose
What goals or outcomes are you hoping to achieve as a result of your exercise program?
Why is this goal important to you? Does it impact anyone else?
What will your life look and feel like when you achieve your goal(s)?
What would your life look and feel like if you DO NOT achieve your goal(s)?
In what time frame do you want to achieve this goal?
Preference
Do you find yourself to be more motivated with a structured plan that must be followed, or do you prefer more variety and freedom knowing the results would be the same?
Structure
Flexibility
Open to both
If you were to choose an activity to reduce stress, what type of activities would you prefer?
Practical & Calm
Adventurous & Loud
Do you prefer to exercise with conventional equipment like machines and free weights, or are you open to trying new things?
Conventional
New equipment
Open to both
Are there any exercises or styles of training you are interested in trying or learning about?
Are there any types of equipment or exercises that you DO NOT like or simply DO NOT want to participate in?
Status
In the last 3 months, what recreational activities and/or exercise have you participated in, and how frequently?
Is your job physically demanding or more sedentary?
Do you have any joint limitations, pain, tightness, or soreness that might affect your experience today or going forward?
Motivation for Purpose
How long have you been wanting to make these changes to your health and fitness?
What has held you back from making these changes up to this point?
Why today? What is different about right now from the things that have held you back in the past?
On a scale of 1 to 10 (10 being MOST CONFIDENT), do you know what you need to do to reach your goal(s)?
On a scale of 1 to 10 (10 being MOST CONFIDENT), how confident are you that you WILL do it?
In what ways do you believe I can help you?
Todays Date
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