Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

What are your fitness goals? *

Lose body fat

Gain muscle mass

Increase strength

Improve cardiovascular endurance

Prepare for a specific event

Improve overall health

Other

Check the box if you now have, or have you had in the past: *

History of heart problems, chest pain, or stroke

Elevated blood pressure

Any chronic illness or condition

Difficulty with physical exercise

Advice from physician not to exercise

Recent surgery (last 12 months)

Pregnancy (now or within last 3 months)

History of breathing or lung problems

Muscle, joint, or back disorder, or any previous injury still affecting you

Diabetes or metabolic syndrome

Thyroid condition

Cigarette smoking habit

Obesity [body mass index (BMI) ≥30 kg/m2]

Elevated blood cholesterol

History of heart problems in immediate family

Hernia, or any condition that may be aggravated by lifting weights or other physical activity

Cancer

Asthma

None of the above