|
First name
MI Last name
Street Address Apt City
State
ZIP Code
Telephone Number
Cell Phone Number E-Mail Address
Age HT
(inches) WT( lbs)
Gender: F
M
Please
check the health benefits and objectives that are most meaningful to you:
Specific areas
of the body to focus on:
Realistically, how many days of the week will you
dedicate to working out on your own?
1
2
3
4
5
6
7
Do you have a membership at a local gym?
Yes
No
if so, where
Exercise habits over the past twelve months:
Athletic and/or active
interests:
Eating habits. Are you on any
diets? Y
N
If so,
please explain
Do you eat breakfast?
Y
N
If so, please describe
How often do you eat? (per day) 1
2
3
4
5
Describe your level of activity in an average day
Check all
conditions that apply to you:
Additional
medical problems or challenges?
Injuries
impacting your ability to perform exercises:
|
