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ONLINE TRAINING ASSESSMENT & PAR Q SIGN UP FORM

Instructions:
STEP #1 Registration: Complete this Assessment & PAR Q Form below,
read agree to terms of the Waiver Release Form and submit.

STEP #2 Payment: Make a Pay Pal, Visa, Master Card, Discover or AMEX
Payment using our Secure PayPal system.


Name: (REQUIRED)
Address: (REQUIRED)
  City: State: Zip:
Phone Number: (With Your Area Code) (REQUIRED)
Email Address: (REQUIRED)
Your Age: (REQUIRED)
Your Height: ft. inches (REQUIRED)
Your Weight: lbs. (REQUIRED)
Body Fat %: (if applicable)
Your Sex: Male     Female (REQUIRED)
Choose which type of program: Home     Gym     Mobile (REQUIRED)
   
FITNESS PAR Q

Please answer all questions accurately and honestly
to allow us to fully determine your individual needs.


1. Do you ever feel weak, fatigued, or sluggish? Yes   No

2. How many meals do you eat each day?

3. Do you know how many calories you eat in a day? Yes   No

4. Do you eat breakfast? Yes   No

5. Are you taking supplements? (i.e. vitamins, protein shakes, etc.) Yes   No

6. Do you crave sugary foods? Yes   No

7. Do you need several cups of coffee to keep you going throughout the day? Yes   No

8. Do you often experience digestive difficulties? Yes   No

9. Have you ever exercised for 6 months or more consistently? Yes   No

10. Do you currently exercise? Yes   No

11. How long have you been exercising?

12. Please select your current type of exercise.
Cardio   Strength Training   Other -

13. Have you reached and maintained your goals? Yes   No

14. Are you happy with the way you look? Yes   No

15. Are you happy with your health? Yes   No

16. Please select your current physical activity level.
Sedentary   Lightly Active   Active   Very Active

17. On a scale of 1 to 10, how serious are you about achieving your goals?
Least - 1   2   3   4   5   6   7   8   9   10 - Most

Please list your desired fitness goals:
Desired Weight:   ~ Desired Body Fat:
Desired Waist Size:   ~ I plan to exercise times a week
Desired Dress or Pant Size:



HEALTH HISTORY ~ HEALTH REPORT


1) Are you Currently taking any medication? Yes No
Type:
Reason:
Type:
Reason:
Type:
Reason:

2) Do you have or have you ever had any of the following conditions?
CONDITION
Heart Attack

Stroke

Chest Pain

Hypertension

Diabetes

Cancer

High Cholesterol

Hernia

Arthritis

Thyroid

Anemia

Other

                           DESCRIPTION
Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


3) Have you ever been injured in any of the following areas?
BODY PART
Neck

Shoulders

Arms

Abdomen

Back

Legs

                    DESCRIPTION ~ WHEN?
Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


4) Are you currently under the care of a physician for any reason at all? Yes No
- If Yes, explain

5) Do you smoke cigarettes? Yes No
- lf yes, how much?

6) Do you know of any physical condition that you have
that could be aggravated by exercising or exerting yourself? Yes No
- If Yes, explain

7) Are you taking any medication which could cause
a reaction while exercising? Yes No
- If Yes, Explain

8) Does your doctor know that you are beginning a new exercise program? Yes No

9) If your doctor knows that you are going to begin
a new exercise program, does he/she object? Yes No
- If Yes, why?



Select Appropriate Plan: Which plan do you want to do?

SCULPTING WORKOUTS


WEIGHT LOSS PROGRAM
(Includes workout & nutrition plan)


MUSCLE MASS PROGRAM
(Includes workout & nutrition plan)


Comments:

Payment Method
PayPal    Visa    Master Card    Discover    AMEX    Other   
I have read and agree to the
Waiver & Release Form   
YES     NOTE: You MUST read, and agree to our Waiver & Release Form
Todays Date:   (Enter Today's Date)
Review that all your information above is correct
then click the SUBMIT button to go to Payment in Step #2


  
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