Full Name
*
First Name
Last Name
Email
*
example@example.com
Gender
Male
Female
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
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12
13
14
15
16
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18
19
20
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22
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25
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28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1997
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
years
Height
cm
What do you do for a living?
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?
Yes
No
Has anyone of your immediate family developed heart disease before the age of 60?
Yes
No
Do any diseases run in your family?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
if yes please list:
Are you a current cigarette smoker?
Yes
No
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
What following goals does best fit in with your goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
What is your goal with your training?
Why?
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
Please rate your motivational level to do what it takes for reach your goal.
1
2
3
4
5
6
7
8
9
10
Are you currently excersising regulary (at least 3x per week)?
Yes
No
If yes what kind of training did you do:
I AGREE TO THE ABOVE TERMS & CONDITIONS!
*
Yes
No
Submit
Should be Empty: