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First Name * Last Name * Date of Birth * Address * City *		State * AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code* Home Telephone* Cellular Telephone Work Telephone Email *

Has a physician ever advised you against exercise?	NO    YES, please explain:
Gender:	Female Pregnant Female    months.
Program I am most interested in:	Personal Training Weight Loss Modern Pilates therapeutic stretch Massage Nutrition
Please explain any health problems you have, medications you take, including dosages and therapies you are under going here.
Do you have any injuries?	NO   YES, please explain:
How do you rate your over-all health?	Please Select: Poor Fair Good Excellent
Consumption of: Alcohol times/week Caffeine times/week	Nicotine/Tobacco times/week Other times/week
How often do you eat out per week?	How Often 1 2 3 4 5+
Do you have a nutritionist?	NO   YES
Do you have any children?	NO   YES, How Many? 1 2 3 4 5+
How would you describe yourself to someone who has never meet you?
What type of home exercise equipment do you own?
What health clubs are you currently a member of?
Have you ever worked with a personal trainer before?	NO     YES, Name of facility:
In what state?	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
For how long?	Number of Months 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 24+
Why would you hire a personal trainer?
Are you training for a specific event, occasion or sport?	NO    YES, Describe:
Describe your current exercise program: Days a week of weight training and body sculpting	Number of Days 0 1 2 3 4 5 6 7
Days a week of cardiovascular activity	Number of Days 0 1 2 3 4 5 6 7
Type of cardiovascular activity
Minutes stretching each week	How Many Minutes: 10 20 30 40 50 60+
What do you want to accomplish immediately with your trainer?
What are your long-range personal fitness and health goals?
What do you expect to accomplish?
What are the 3 most convenient days and times for you to meet with your trainer?	Monday Tuesday Wednesday Thursday Friday Saturday Morning Afternoon Evening Night
	Monday Tuesday Wednesday Thursday Friday Saturday Morning Afternoon Evening Night
	Monday Tuesday Wednesday Thursday Friday Saturday Morning Afternoon Evening Night
I want to meet with my trainer:	Days per week 2 3 4 5 6 7