Twin Fitness Professional Personal Training

Registration Form

First Name
Middle Name:
Last Name
Address
City
State
Zip
Home Phone
Cell Phone
Business Phone
E-Mail Address
Occupation
Emergency Contact
Phone
Age
Date of Birth
Weight
Height
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
Additonal 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 Circuit Training Treadmill Free Weights Machine Weights EFX
Other activites or machines of interest?
Do you currently have an illness or infection?	Yes No
Have you been hospitalized or had major surgery within the last year?	Yes No
Are you pregnant or have you given birth within the last two months?	Yes No
Do you have a history of the following conditions?	Diabetes Thyroid Disorder High Blood Pressure Smoking Liver Disorder High Cholesteral 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?	Yes No
If yes, please explain
Do you have any other medical condition not previously mentioned?	Yes No
If yes, please explain
Are you currently involved in an exercise program?	Yes No