First Name
Last Name
Email Address
Phone Number
Birth Date
Shoulder Issues
Back Issue
Knee Issue
Do you have asthma or lung issues
Hip Issues
What Health Insurance Company Do You Have
You have heart disease
Do you ever feel weak, fatigued or sluggish?
Do you crave sugary foods?
Do you need caffiene during the day for energy?
Do you often experience digestive difficulties?
How many meals do you eat each day?
Do you eat breakfast?
Do you have high cholesterol?
Has a doctor told you that you have heart trouble?
Have bone/joint issues that inhibit activity?
Do/have you had high blood pressure?
Are you 65+ and not accustomed to exercise?
Any other issues that could inhibit activity?
How long have you been exercising?
Are you happy with your health and look?
1-10 (Best) how serious are you about your goals?
Emergency Contact Name
Emergency Contact Phone