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Name
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First Name
Last Name
Email
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Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Gender
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Male
Female
Date of Birth
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Month
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Date
Height (Inches)
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Weight (Pounds)
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Do You Currently Workout?
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Yes
No
If Yes, What type of workouts?
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What is your specific goal and why?
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How often would you like to meet with your personal trainer or attend classes to meet your goal:
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Are there any obstacles that may prevent you from achieving your goal? On a scale from 1-10 (10 being most important) how important is this to you?
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Interested In: (Check all that apply):
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Weight Loss
Cardiovascular Training
Increased Energy
Nutrition
Build Muscle
Personalized Workout
Increased Strength
Lifestyle Change
Toning/Definition
Time Efficient Training
Flexibility
Motivation
Best/Preferred Time:
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Morning
Afternoon
Evening
In the three areas of fitness (i.e weights, cardio, nutrition) which would you like to improve the most?
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Weights
Cardio
Nutrition
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Health History
Has your doctor ever said you had a heart or health condition and recommended only medically supervised physical activity?
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Yes
No
Do you have chest pain brought on by physical activity?
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Yes
No
Do you tend to lose consciousness or fall over as a result of dizziness?
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Yes
No
Has a doctor ever recommended medication for your blood pressure or heart condition?
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Yes
No
Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
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Yes
No
Are you aware, through your own experience or a doctor’s advice, of any other physical reason against your exercising without medical supervision?
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Yes
No
Do you smoke?
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Yes
No
Do you have any family history that could cause you not to be able to do rigorous exercises?
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Yes
No
Are you over the age of 65 and/or not accustomed to vigorous exercise?
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Yes
No
* If you answered YES to any of the questions above, please answer and initial the following questions:
Have you consulted a physician regarding increasing your physical activity?
Yes
No
If you have answered NO to question 8, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?
Yes
No
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