Name:
Address:
City:
State:
Zip:
E-mail:
Sex:
Age:

Medical History-Please check all that apply

Arthritis Asthma Back Pain High Blood Pressure Joint Pain
Coronary Disease Pregnant Foot Pain Diabetic Hernia
Surgery Shortness of Breath Smoke Chest Pain Elevated Cholesterol

Current Medications and/or recent ailments:

Primary Goals
Present Weight:
Bodyfat %:
Target Weight:
Pushups:
Situps:
Pullups:
Dips:
1 Mile Run:
1.5 Mile Run:
500 Yd Swim:

What type of equipment do you have access to?
Full Gym Swimming Pool 400m Track Free Weights Pullup/Dip Bar
Other equipment not listed that you have access to:

What days per week are you available to work out?
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Workout Program:

Consent:
By accepting this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. In accepting this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death. I also understand that I may stop any training session at anytime. By accepting this document, I assume all risk for my health and well being and any resultant injury or mishap that may affect my well being or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures.
I understand and accept this document