Name *

First Name

Last Name

Phone

(###)

###

####

Emergency Contact *

Just in case

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

When would like to achieve this goal by? *

MM

DD

YYYY

How stressful is your average day? *

Not very stressful

Sometimes stressful

Extremely stressful

Does exercise help with managing stress? *

No

Yes

Sometimes

Are you under or have been under physician’s care in the last 5 years for any ailment or specific injury? * *

No

Yes

Are you taking any prescription medications that could have side effects during exercise?

No

Yes

Do you currently smoke? *

No

Yes

Do you drink alcohol? *

No

Yes

Do you ever experience chest pains, high blood pressure, shortness of breath, abdominal pain, frequent heartburn, urinary problems, joint swelling, numbness, temporary loss of vision, loss of consciousness? *

If yes, please consult with a physician for proper clearance to continue.

No

Yes

Are you pregnant? *

No

Yes