Back World Gym Burpengary PT Questionnaire Full Name(Required) First Phone Number(Required)Email(Required) Preferred Contact Method(Required) Phone Call Email Text Message Date of Birth(Required) DD slash MM slash YYYY What interest you?(Required) Personal Training Services Allied Health Nutrition Consultation Goals (Pick up to 2 options)(Required) Weight Loss Muscle Gain Respiratory Fitness Balance/Mobility Mental Health Other Do you have any of the following conditions(Required) Current or previous Heart Condition/s Suffered a stroke Unexplained pains or discomfort in your chest at rest of during exercise Have you ever felt faint, dizzy or lose balance during physical activity/exercise? Type 1 (I) Diabetes Type 2 (II) Diabetes Pregnant or recently given birth (<12 months) None Other Do you have any other conditions that may require special considerations for you to exercise? Including but not limited to Current or Previous Injuries,(Required)Preference of Trainer Male Female No Preference Have you had Experience within a Gym Setting No experience <6 months 6-12 months 12-24 months >24 months Are you confident with compound movements? Yes No How many Steps do you achieve per day? <3000 Steps 3000-6000 Steps 6000-10000 Steps >10000 Steps How Many days per week do you train, or plan on training? 2 3 4 5 Current Physical Activity Sedentary: Minimal movement beyond daily tasks, mostly sitting or reclining Lightly Active: Includes light exercise or daily activities like walking, light housework, or casual cycling Moderately Active: Regular moderate-intensity activities such as brisk walking, resistance training (<3 times per week), or casual sports Very Active: High-intensity activities like running, aerobics, resistance training (> 3 times per week), or vigorous sports
