All Fitness Gurus, Nationwide and accredited fitness expert

First Name

example: Joe

Last Name

example: Smith

Address

City

example: Beverly Hills

State

Zip Code
example: 90210

Home Phone
Ext.

Work Phone
Ext.

Mobile Phone

Best Time to contact you

EMail Address

example: joe@joesmith.com

Age

Date of Birth

Height

Weight

Sex

Health and Exercise History

What type of Trainer are you looking for? (Required)

Have you ever participated in an exercise program?

If yes, what was your experience?

Are you currently taking any medications or drugs?

If yes, which one and what kind of condition does these medications or drugs treats?

Have you experienced a history of heart problems, chest pain, or stroke?

If yes, please explain?

Does your immediate family have a history of heart problems?

Do you have increased blood pressure?

Have you been hospitalized or had recent surgery in the past year?

Have you experienced hernia, or any condition that may be aggravated by lifting weights?

Are you pregnant or have you given birth within the last 3 months?

Do you have a history of breathing or lung problems?

If yes, please explain?

Do you smoke cigarettes?

Do you have a muscle, back, kidney, or joint disorder?

Have you experienced an injury recently or in the past?

Are you currently receiving physical therapy treatments?

Do you have a diabetes or thyroid condition?

Do you have increased blood cholesterol?

Is there a health issue not mentioned in this questionnaire that would keep you from participating in regular exercise?