| Name |
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| Street Address |
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| City |
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| State |
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| ZIP Code |
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| Phone |
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| Email |
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| Gender |
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| Age |
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| Weight |
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| Height |
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| Blood Pressure |
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| When was your last physical examintaion? |
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| What were the results? |
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| List any medications you are currently taking, or have taken in the past 6 months. |
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| List any operations that you have had. (Include Date) |
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Indicate any of the following which currently, or have existed, in the past and note when.
(Example: Arthritis, Cancer, Joint Problems,High Blood Pressure, Diabetes, Back Pain/Injury, High Cholesterol) |
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| Are you pregnant or trying to become? |
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| How would you rate your current eating habits? |
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| How many times per day do you eat? |
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| Do you take supplements? |
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| How often do you perform moderate exercise? |
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| How many hours a week do you work? |
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| How do you spend your workday? |
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| How would you rate your current fitness level? (Poor Moderate Excellent Competitive Athlete) |
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| How often do you perform resistance training? |
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| List any other factors which might affect your safe participation in a fitness program. |
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| Personal Goals (Weight Loss, Strengthen Bones, Improve Strength, Improve Flexibility, Improve Posture, Tone and Firm) |
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| How would you like to be contacted? |
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| When would you like to begin? |
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| Do you prefer a male or female instructor? |
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| What is your availability? |
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| How did you hear about us? |
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| Are you a member of a local gym? |
If so, where? |
| Have you had a trainer in the past? |
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| Would you be interested in acupuncture, massage, pilates, yoga, kick boxing, physical therapy, nutritional blood testing, group training sessions, or chiropractic services? |
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