EmailMe Form - Over 40 Fitness Information Sheet

EmailMeForm

Are YOU ready to COMMIT 100%, NO Excuses, NO BS *
YES
NO
Name *
First Last
Email *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone *
### - ### - ####
Date Time *
MM / DD / YYYY
Current Weight *
Height *
Bodyfat % (if known)
Age *
Actvity

Exercise Type Times Per Week Duration Intensity

#1

#2

#3

#4
Lifestyle & Goals *
Sedentary
Moderately Active
Active
Very Active
Can't Stop, Won't Stop
Describe Goals *
Shed Body Fat
Maintain
Gain Muscle
Sports Specific
Bodybuilding
Prenatal/Postnatall
General Health
Workout Preference *
Gym: Machines
Gym: Weights
Bodyweight
Home
HIIT
Circuit
Sports Specific
Muscle Specific
Push/Pull
Other
Explain Other Preference Above
Cardio Preference *
Treadmill
Eliptical
Stationary Bike
Running Outdoors
Stairs
Bike Outdoors
Sprints
Rowing
Calisthetics
Sports Specific
Other
Explain Other Preference Above
Goal Weight or Body Fat % *
Has your doctor ever said that you have a heart condition and that you should
only perform physical activity recommended by a doctor? *
YES
NO
Do you feel pain in your chest when you perform physical activity? *
YES
NO
In the past month, have you had chest pain when you were not performing any
physical activity? *
YES
NO
Do you lose your balance because of dizziness or do you ever lose consciousness? *
YES
NO
Do you have a bone or joint problem that could be made worse by a change in
your physical activity? *
YES
NO
Is your doctor currently prescribing any medication for your blood pressure or
for a heart condition? *
YES
NO
Do you know of any other reason why you should not engage in physical
activity? *
YES
NO
If you answered YES to any of the above questions please explain in full detail below. All information will be kept confidential.
Additional Notes for your coach

	Exercise Type	Times Per Week	Duration	Intensity
#1
#2
#3
#4