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Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Birth Date
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Month
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Day
Year
Date
Current Weight
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Approximate
Describe your desired body a year from now.
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What would you like to accomplish, feel, do, etc...
Are you currently a member at Roman Empire Gym?
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Yes
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Have you worked with a personal trainer before?
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No
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