| * Name: | |
| * Birthdate | |
| * Phone number | |
| * Email: | |
| * Where do you work? List work phone number if applicible | |
| * Hours of work / days per week | |
| Medical History (any diagnosis/allergies/recent surgeries/list all medications (prescription/herbal and dosages) | |
| Musculoskeletal History (any back/neck pain, injuries etc when? Treatment you’ve had and is it resolved?) | |
| * Activity History (describe your exercise routine in the last 3 mos in detail/wts, reps, cardio) | |
| * Nutrition History (describe in detail a typical daily food intake - include time of day – and PLEASE be honest!!!) | |
| Foods you CANNOT eat (allergies, dislikes etc) | |
| Top 3 personal fitness goals (run a 10km race/marathon/lose weight/gain wt/etc) | |
| What is your current height/weight | |
| Have you gained/lost weight in the last 3 mos? If so how did you do it? | |
| Where do you intend to exercise? Please list the equipment you have available if it is a home gym: | |
| Do you intend to train by yourself or with a training partner (also what time of day)? | |
| Have you tried to lose/gain weight before? If so, why do you think you did not achieve the results that you are looking for? | |
| Please indicate which (if any) of the following information you would like featured on my web site: | |
* SPAM Protection:
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