Fit for 22 Challenge Registration

Contact Information

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Date

Emergency Contact

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Pre-existing medical conditions:(Please be as detailed as possible including type of pain-i.e. neck, back, knee, etc).

What are your fitness goals?

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

Do you frequently have pains in your chest when you perform physical activity?

Do you experience chest pain when not engaging in physical activity?

Do you lose your balance due to dizziness or do you ever lose consciousness?

Do you have a bone, joint or any other health problems that causes you pain or limitations that must be addressed when engaged in an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?

Are you currently pregnant or have you given birth within the last 6 months?

Have you had a recent surgery? (within the last 12 months)

If yes to the above question, please explain. (include up to last 3-5 years as necessary that may impact workout)

Do you take any medications, either prescription or non-prescription, on a regular basis?

If yes, what is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

Do you smoke?

If yes, how many times per day?

Do you drink alcohol?

If yes, how many glasses per week?

How many hours do you regularly sleep at night?

Describe your job: Sedentary, Active, or Physically Demanding?

Does your job require travel?

On a scale of 1-10, how would you rate your stress level?

List your 3 biggest sources of stress: (i.e. school, work, kids, etc.)

Is anyone in your family overweight? (mother, father, sibling, or grandparent)

Were you overweight as a child? If so, what age?

Have you been exercising consistently for the past 3 months?

On a scale of 1-10, how would you rate your present fitness level?

How often do you take part in physical exercise? 1-2x/week 3-4x/week 5-7x/week

What physical activities are you presently involved in?

How did you hear about us?

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