Member Questionnaire | Agents of Change Personal Training

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Height

Weight

Body Fat Percentage (if known)

Are you active or sedentary at work? How many hours?

On average, how often are you strength training per week?

On average, how often are you doing cardio per week?

If currently exercising, what is the intensity level from 1-5 with 5 being very intense

If you currently strength train, what is your split?

Has a physician or medial professional indicated there are exercises you should not perform?

Yes

No

If yes to the above, please list exercises below

Do you currently track macros and/or calories

Yes

No

If yes, what is your current macro breakdown and/or calorie count per day?

What time of day do you normally eat and what food do you typically eat at each meal?

Are you allergic to any foods?

Yes

No

If yes, what foods?

Is there any food you absolutely cannot eat for a reason other than an allergy?

I have read and agree with the Waiver and Liability. *

Signature

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