Personal Training Request Form

Welcome to your first step toward a stronger, healthier you! Dominique Mckane is a certified personal trainer with over 15 years of experience in strength training, conditioning, nutrition coaching, and post-partum recovery. A U.S. Army veteran and Brazilian Jiu Jitsu practitioner, Dominique brings discipline, compassion, and personalized expertise to every training session. Whether you're looking to build muscle, lose weight, increase mobility, or regain strength after pregnancy, Dominique will tailor a program to meet your unique goals, lifestyle, and fitness level.

Please complete the following form so we can begin building a plan that fits YOU. All information is kept confidential and used solely to provide the best possible support on your fitness journey.

Sign in to Google to save your progress. Learn more
Email *

First I need some personal information. Please provide your full name, date of birth, phone number, and one emergency contact.

 *
  What are your primary fitness goals? (Check all that apply)

 *
Required
If you chose "other" for the previous question, please describe:

otherwise skip this question.
 *
  Do you have any medical conditions or injuries? (Please describe)  If no conditions or injuries please put NA *
Are you currently under a doctor's care or physical therapy?   *

Do you have any physical limitations or chronic pain (e.g., back, knees, joints)?

 *

Have you had surgery in the past 12 months?

 *

Are you pregnant, post-partum, or breastfeeding?

 *

Are you currently taking any medications or supplements? (List if relevant)

  Have you worked with a personal trainer before?  
Clear selection
  What is your current activity level?
Clear selection

What types of workouts or sports have you done in the past?

Are there any exercises or movements you dislike or want to avoid?

Are there any exercises you enjoy?

How would you describe your current eating habits?

Are you interested in nutrition coaching as part of your program?

  Do you have any dietary restrictions or food allergies?  
How many hours of sleep do you get per night on average?  
  How would you rate your current stress levels? (Low / Medium / High)  
Low
High
Clear selection

1. What days/times are you generally available for training?

2. Do you prefer in-person or virtual training (if offered)?

3. Would you like to train 1-on-1 or in a small group (if available)?

4. How often do you want to train each week?

  Is there anything else you'd like to share with me about you, your lifestyle, or your goals?  
I cannot wait to get started helping you get to a better you!!
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms