Name *

First Name

Last Name

Date *

Please fill out today's date

MM

DD

YYYY

Name

First Name

Last Name

Gender *

Male

Female

Birthday

You will be added to the birthday list

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile

(###)

###

####

Home

(###)

###

####

Work

(###)

###

####

Has your doctor ever told you that you have heart trouble? *

Yes

No

Do you currently have diabetes? *

Yes

No

Are you male 40 years or older, or female 50 years or older? *

Yes

No

Have you had pains in your heart or chest? *

Yes

No

Do you at times feel faint or have spells of severe dizziness? *

Yes

No

Do you have asthma, emphysema or bronchitis? *

Yes

No

Do you currently have thyroid problems? *

Yes

No

Have you had any of the following: Shortness of breath especially upon exertion; heart palpitations; leg cramps during walking; or persistent swelling around the ankles? *

Yes

No

Has a doctor ever told you about bone or joint problems such as arthritis that has been aggravated by exercise or might be made worse with exercise? *

Yes

No

Are you pregnant? *

Yes

No

Has a doctor ever told you that your blood pressure was too high? *

Yes

No

Have your parents, brothers, or sisters suffered from heart disease before the age of 55? *

Yes

No

Are you currently a cigarette smoker or have you smoked within the last 6 months? *

Yes

No

Has your doctor told you that your cholesterol level is too high? *

Yes

No

Select all that apply: *

Weight Loss

Flexibility

Reduce Body Fat

Improve Physical Strength

Improve Cardiovascular Health

Stop Smoking

Improve Posture

Improve Eating Habits

Reduce Prescription Drug Use

Reduce Stress

Overall Wellness

Rehabilitation

Healthier Heart

Improve Mobility/Stability

Quit Drinking

Streamline Workout

Strengthen Bones

Gain Muscle

Sport Specific Training

Increased Energy

Motivation

Reduce Risk of Disease

Improve Balance & Coordination

Improve Sleep Quality

Exercise More Regularly

Lower Cholesterol

Tone & Firm

Select all that apply:

Neck

Lower Back

Hands

Shoulders

Hips

Feet

Arms

Knees

Are you currently exercising on a regular basis?

Yes

No

Do you strength train?

Yes

No

Do you cardiovascular exercise?

Yes

No

Have you ever worked with a personal trainer?

It doesn't have to be recent, but any time in the past also counts.

Yes

No

How would you describe your current eating habits?

Very Good

Needs Improvement

Pretty Good

Poor

Just OK

Do you often feel stressed?

Yes

No

Sometimes

Do you take a multivitamin?

Yes

No