Information/Enrollment Form

** All information is considered confidential, and will only be used
for the purposes of designing a training and nutritional program. **

Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-Mail
Confirm E-mail
Date of Birth (mm/dd/yyyy)
Sex Male Female
Height in ft. and inches (example "5ft10in")
Weight in lbs.

What is your weekly schedule like? (Be specific about things like work, school, hobbies, responsibilities, sleep, etc)

What is your biggest obstacle to working out?

Current Exercise Routine -- please select ANY and ALL exercises programs that you currently participate in.

 

  Cardiovascular Training  
  Type (Check all that apply) Frequency Duration
  Walk
  Jog
  Swim
  Step or Hi/Lo Aerobics
  Kickbox
  Other  
       
  Mind/Body   Duration
  Yoga
  Pilates
       
  Strength Training    
  Dumbbells  
  Weight Machines  
       

Fitness Equipment: (select ALL equipment that you either own or have access to):

  Treadmill                    Stationary Bike Dumbbells
  Resistance Band (s) Step Bench
  Exercise Stability Ball Jump Rope
 

I belong to a fitness club    

I work out at home

Other equipment   

     (please specify)

How many times a day do you eat?

two three four five six

What training options do you have available to you?

I belong to a gym I work out at home I have no options I work out at an office gym
How many days a week do you currently work out?
none one two three four five or more

How many times a week could you realistically work out?

two three four five six
How long can you commit to working out for during each session?
20 minutes 30 minutes 45 minutes 60 minutes 90+ minutes  

Medical History: (please select ALL that apply)

  Been seen by a physician in the past 12 months

Currently pregnant

Diagnosed with heart disease

Had a stroke

Have arthritis

Have diabetes

Previous allergic reaction to exercise

Currently taking medication for chronic condition

         What is the medication for?      

        

Recent fracture, sprain or dislocation

Other conditions we should know about (please specify):

Cleared by a physician to exercise

Given birth in the past 6 months

Had a heart attack

Have high blood pressure

Have asthma

Experienced seizures

Previous chest pain or numbness

Currently have a cold or influenza

Recently had surgery

 

 

 


Any other information you feel may apply OR if you answered yes to any of the above Please explain here?

Release of Liability

Do you agree to the release of liability terms detailed above?

  By choosing Yes, you indicate that you have read the Release of Liability above, fully understand and accept the terms and that you have given up substantial rights by accepting these terms.

Membership Agreement and Terms of Use

 

Do you agree to the membership agreement and terms of use detailed above?

By choosing Yes, you indicate that you have read the Membership Agreement and Terms of Use above and fully understand and accept the terms.

Write Name:


 

 
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