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Registration Form
Posted
March 19th, 2008
by admin
Registration Form
Contact Information
First Name:
*
Please enter your first name.
Last Name:
*
Please enter your Last Name.
Address:
*
City:
*
State:
*
Zip:
*
Please enter 5-digit zip.
Email:
*
Telephone:
*
Please enter a 10 digit telephone number.
Personal Information
Date of Birth:
month
January
February
March
April
May
June
July
August
September
October
November
December
day
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Resting Blood Pressure:
If known.
Resting Heart Rate:
If known.
How did you hear about us?:
How many hours a week do you work?:
*
Is your job considered stressful?:
Do you enjoy exercise?:
*
select...
Yes
No
If no, why not?:
Be specific
Are you currently exercising?:
*
select...
Yes
No
If yes, what kind?:
Have you worked with a trainer before?:
*
select...
Yes
No
If so, how long did you work with your trainer?:
What are your expectations of your trainer?:
*
What do you do for recreation and entertainment?:
*
How long have you been wanting to transform your body?:
*
How many days a week can you work out?:
*
What are the best days and times?:
*
What are your top 4 goals for this program?:
*
Eating Habits
Describe your eating habits and diets.
Do you normally eat breakfast?:
*
select...
Yes
No
How many meals a day do you normally eat?:
*
Are you currently taking any supplements?:
*
select...
Yes
No
Are you currently on any diet?:
*
select...
Yes
No
Have you ever been on a diet?:
*
select...
Yes
No
What were your results from these diets?:
*
Do you cook, or have someone cook for you?:
*
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