APPLICATION FORM

Name *

First Name

Last Name

What are your main reasons for starting the program you selected? *

General conditioning

Weight/Fat loss

Muscular Strength

Aerobic Fitness

Stress Management

Improve Your Relationship with Food

Improve Your Relationship with Your Body and Self Esteem

Appearance

No Time

Lack of Structure

How committed are you to achieving your fitness goals? *

Very committed

Semi committed

Unsure

Not very committed

At what rate do you want to see results?

Rapidly

Moderately

If applicable, how would you describe your level of experience in the gym or with weight training? *

Beginner - Under 6 months or no experience lifting weights.

Intermediate - 1-2 years experience lifting weights.

Advanced - 3yrs + experience lifting weights.

Did your physician recommend that you lose weight and/or start an exercise program? *

Yes

No

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *

Yes

No

Do you lose your balance due to dizziness or do you ever lose consciousness? *

Yes

No

Are you pregnant now or have given birth within the last 6 months? *

Yes

No