General Health Form
First Name
Last Name
Primary E-Mail Address
Male / Female
Female
Male
Birthdate
Height
Weight (lbs)
Desired Weight (lbs)
What is your fitness goal?
Weight Loss / Tone Up
Maintain Current Weight
Weight / Mass Gain
Speed, Agility & Quickness
Which statement best describes you?
I have a hard time gaining weight.
I can lose or gain weight as needed
I have a hard time losing weight.
Accurately rate your activity level:
Sedentary
Moderately Active
Active
Very Active
Describe your weekly exercise routine:
Program(s) you are interested in:
1-on-1 Personal Fitness Training
Personalized Nutrition/Food Plan
SAQ Training
Online Personal Training
Online Digital Training
Are you pregnant?
No
Yes
Are you over 65 & not used to exercise?
No
Yes
Do you have any of the following:
Heart Disease
Kidney Disease
Liver Disease
Diabetes
Anemia
Hypoglycemia
Hypertension
Dizziness/Loss of Balance
Loss of Consciousness
Any family history of the following:
Heart Disease
Liver Disease
Cancer
Stroke
Diabetes
Osteoporosis
Hypoglycemia
Hypertension