Date
Date
Name *
Name
Date of Birth *
Date of Birth
My Occupation is (check all that apply)
Phone Number
Phone Number
Home Address
Home Address
ICE Phone Number
ICE Phone Number
FITNESS HISTORY
Have exercise programs been successful for you in the past?
HEALTH HISTORY
Have you or your immediate family members (mother/father/siblings) ever been diagnosed with (check all that apply):
CURRENT LIFESTYLE
Do you consider your overall activity level to be:
Are you a cigarette smoker?
Please rate the following statements:
Please rate the following statements:
I am in control of my eating.
I generally sleep well.
I have enough energy to get through my day.
I drink 8 glasses of water per day.
I am healthfully losing, maintaining, or gaining weight.
I enjoy the benefits of exercise.
I regularly exercise.
My body is healthy and fit.
My stress is well managed.
The current state of my body and fitness enhances my life.
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