City of Coquitlam
Personal Training
Client Profile Package
Poirier Sport and Leisure Complex
City Centre Aquatic Complex
City of Coquitlam
Personal Training
Client Profile Package
Personal Training Client Information Package
Before You Begin:
If you are between the ages of 15 to 69, take this short questionnaire to determine if you should contact your
doctor before getting active. If you are over the age of 69, consult with your doctor before beginning a new
fitness routine.
PAR-Q+
Assessing Your Needs:
All information received on this form will be treated as strictly confidential. Please fill out the forms as
accurately as possible. This information is essential to develop a program that addresses your needs,
goals and interests in a safe and effective manner.
Date:
Last Name:
Date of Birth: (m)
Given Name:
(d)
(y)
Age:
Address:
Phone: Home
Cell
Email:
Occupation:
Emergency Contact:
Phone:
Relation:
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Help Us to Help You:
Why did you decide to invest in a Personal Trainer?
How can your Personal Trainer motivate you?
What do you think a Personal Trainer will help you accomplish?
How did you hear about Coquitlam’s personal training packages?
Lifestyle and Behaviour Related Questions:
On a scale of 1-10, how would you rate your stress levels (1=Very Low | 10=Very High)
How many hours per night do you sleep?
Overall, how would you rate your nutrition?
Low
Medium
High
List three areas of nutrition you would like to improve:
1.
__________________
2.
__________________
3.
__________________
Do you smoke?
Yes
No
Do you take any medications, either prescription or non-prescription on a regular basis?
If yes, please list:
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Yes
No
Fitness Related Questions:
Are you satisfied with your current level of fitness?
Yes
No
Per week, how often do you participate in physical activity?
5- 7 times
3-4 times
1-2 times
not at all
If active, what exercises do you engage in (please list)
Activity
Frequency
Length of Time
Easy/Moderate/High
Goal Setting
Please list in priority, what fitness goals you would like to achieve in the next 12 weeks.
a) _
b) _
c) _
Please list in order of priority, what fitness goals you would like to achieve over the next 6-12 months.
a) _
b) _
c) _
What is preventing you form attaining the goals right now? Explain.
How will you feel once you have achieved your short term and long term goals?
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Session Information Form
To be completed in full prior to arranging training sessions.
How many times per week would you like to work with your trainer?
How many times per week are you willing to work on your own?
Please indicate the days and times that you are available to book your first appointment.
Please check all spaces that apply.
Times
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
6:00 a.m.
9:00 a.m.
9:00 a.m.
12:00 p.m.
12:00 p.m.
5:00 p.m.
5:00 p.m.
10:00 p.m.
Is there a particular trainer you would like to work with?
Please indicate the package you have in mind.
Number of Sessions
Time
Price*
Package selection
Private Training with a Registered Personal Trainer
1 private session
1 hour per session
$55.00
3 private sessions
1 hour per session
$157.41
5 private sessions
1 hour per session
$250.00
10 private sessions
1 hour per session
$474.00
Tandem Training with a Registered Personal Trainer
[Offer valid for 2 people signing up at the same time, for the same session.]
1 private session
1 hour per session
$78.00
3 private sessions
1 hour per session
$225.99
5 private sessions
1 hour per session
$358.00
10 private sessions
1 hour per session
$680.00
*Prices do not include taxes
Note: Any cancellation of appointments with your trainer requires 24 hour notice.
For more information please contact:
Poirier Sport and Leisure Complex
633 Poirier St.
Coquitlam, B.C.
Phone: 604.927.6027
City Centre Aquatic Complex
1210 Pinetree Way,
Coquitlam, B.C.
Phone: 604.927.6999
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