Personal Training Client Information Form


If you're between the 15 – 69 years old, please complete this online questionnaire to determine if you should contact your doctor before getting active. If you are older than 69 years old, consult with your doctor before beginning a new fitness routine.


The information you provide is essential to develop a fitness progam to meet your needs, goals and interests in a safe, effective manner. All information will be kept strictly confidential.

General Information

Please provide a name, phone number and relationship with you.

Assessing Your Needs

Lifestyle and Behaviour

On a scale of 1 to 10, how would you rate your stress level? ( 1 = extremly low, 10 = extremely high)
Do you take any medications, either prescription or non-prescription on a regular basis?
Do you smoke?

Fitness Related Questions

Are you satisfied with your current level of fitness?
How often do you participate in physical activity per week?

Goal Setting

Training Session Information

Personal Training Packages

If you've decided, please indicate which personal training package you are interested in purchasing. For more information about these packages, including prices, please visit Personal Training > Personal Training Packages.  

Collection and Use of Personal Information

By checking "I consent" you are consenting to the voluntarily collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act. The information provided by you will be used solely for the purpose of providing you with personal training services.Your information will not be used for any other purpose. If you have any questions about the collection, correction and/or use of your personal information please contact the Health & Fitness Program Coordinator, City of Coquitlam, Parks, Recreation and Culture at 604-927-6004.*
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