Personal Training Member Profile Step 1 of 16 6% This field is hidden when viewing the formDate MM slash DD slash YYYY About YouYour Name(Required) First Last Age(Required)Your Email Address(Required) Current Weight(Required)Height(Required)Occupation(Required) Are you currently working out?(Required) Yes No Other Do you smoke?(Required) Yes No Other How long have you been thinking about living a healthier lifestyle?(Required) At what age would you consider yourself to have been in the best shape of your life?(Required) Are you currently on any medications or supplements? Please list the medication and the reason you are taking(Required) Do you have any special needs? (i.e. pregnant, joint/bone problems, high blood pressure, past/present injuries)(Required) What are your main reasons for hiring a trainer?(Required) Overall Health Increased Strength Toning/Definition Meal Plans Weight Loss Increased Energy Select All Has your doctor ever said you have a heart condition and recommended only medically supervised physical activity?(Required) Yes No Do you have chest pain brought on by physical activity?(Required) Yes No Has a doctor ever recommended medication for your blood pressure or heart condition?(Required) Yes No Do you tend to lose consciousness or fall over as a result of dizziness?(Required) Yes No Are you aware, through your own experience or a doctor’s advice, of any other physical reason against your exercising without medical supervision?(Required) Yes No Do you have a bone or joint problem that could be aggravated by the proposed physical activity?(Required) Yes No Are you over the age of 65 and not accustomed to vigorous exercise?(Required) Yes No Have you consulted a physician regarding increasing your physical activity and/or performing a fitness assessment?(Required) Yes No Will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?(Required) Yes No Goal EvaluationWhat obstacles do you think are preventing you from reaching your goals?(Required) What is your goal and how do you plan to get there? Realistic time frame?(Required) Describe your diet/water intake (include alcohol and other caloric drinks)(Required) How Can We Reach You?We would love to chat with you. How can we get in touch?Preferred Method of ContactEmailTextYour Phone(Required) Are you ready to take the next step?Submit this form to be taken to the booking page for your FREE fitness assessment!Your Comments/Questions