First Name
Last Name
Address
City
State
Zip
Home Phone
Cell Phone
Business Phone
E-Mail Address
Occupation
Age
Date of Birth
Height
Weight
Emergency Contact
Emergency Contact Phone
How Did You Hear About Us?
Check as many of the following as appropriate
Improve Muscle Tone
Improve Flexibility
Weight Loss
Improve Aerobic Fitness
Improve Muscle Strength
Weight Gain
Sports Specific Conditioning
Lower Body Fat
Increase Muscle Mass
Stress Management
Additional Goals If Any
Are you currently involved in an exercise program?
Yes
No
If yes, how long have you been training on a regular basis?
Aerobic Activity Number of Days Per Week
Aerobic Activity Minutes Per Day
Strength Training Number of Days Per Week
Strength Training Minutes Per Day
What level of exerciser would you describe yourself as?
Beginner
Intermediate
Advanced
Please select from the following list of activities or machines that are of particular interest to you?
Walking
Biking
Stair Master
Circuit Training
Treadmill
Free Weights
Machine Weights
EFX
Other activites or machines of interest?
Do you currently have an illness or infection?
Have you been hospitalized or had major surgery within the last year?
Are you pregnant or have you given birth within the last two months?
Do you have a history of the following conditions?
Diabetes
Thyroid Disorder
High Blood Pressure
Smoking
Liver Disorder
High Cholesterol
Kidney Disease
Asthma
Heart Attack
Arteriosclerosis
Bronchitis
Emphysema
Irregular Heartbeat
Family History of Heart Disease
Do you have a history of any of the following injuries or orthopedic issues?
Joint Problems
Tendentious
Arthritis
Bad Back
Bursitis
Bad Knees
Are you currently receiving physical therapy?
If yes, please explain
Do you have any other medical condition not previously mentioned?
How many shows have you competed in? (name your placements)
What Competition category are you wanting to compete in?
Bikini
Figure
Not Sure
Nutrition - Any food allergies?
Give an example of a typical day of food
Breakfast
Lunch
Dinner
Any adverse effects to Caffeine?
Have you ever/ or are you currently taking any weight loss supplement?