Name: Age: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Home Phone Number: Cell Number: Work Number: Email address: Which Location are you interested in? Burlington Mississauga Hamilton Which Class are you interested in? Burlington Morning Class: Every Wednesday Mississauga TBA Burlington Evening Class: Every Wednesday Hamilton Morning Class: TBA Do you currently train anywhere else? (please specify) Primary Goals: Improve strength Improve cardiovascular fitness Fat loss General fitness Build muscle Improve function Tone-up Rehabilitation Reduce back pain Sport specific Injury prevention Improve flexibility Reduce stress Increase energy Background & Medical Information  Occupation Do you suffer from back pain? Yes No Do you have tension or soreness in a specific area? Yes No Are you pregnant? Yes No Do you have high blood pressure? Yes No Do you have high cholesterol? Yes No Have you ever had surgery?  Explain Do you experience stiff, swollen or painful joints? Yes No Do you have difficulty falling asleep? Yes  No Do you have difficulty staying asleep? Yes No Do you have difficulty waking up in the morning? Yes No What time of day do you usually experience the least amount of energy? What time of day do you usually experience the most amount of energy? Have you ever been advised by a physician to avoid any type of exercise? Yes No Do you have any allergies? Yes No Have you ever seen a Nutritionist/Registered Dietician? Yes No Do you smoke? Yes No Have you smoked in the past?  Yes No On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career. 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your personal life. 1 2 3 4 5 6 7 8 9 10 Please list any medications you are currently taking. Have you ever had any of the following (if more than 1 please elaborate under "other") physical therapy chiropractic massage acupuncture other Please elaborate. What time do you usually go to bed at night? 01 02 03 04 05 06 07 08 09 10 11 12 :00 :30 AM PM What time do you usually wake in the morning? 01 02 03 04 05 06 07 08 09 10 11 12 :00 :30 AM PM Do you drink coffee? If so, how much?  Yes No 0 1cup a day 2 cups a day 3+cups a day How many meals do you eat each day? List the number and time of day you usually eat these meals. Do you take supplements, if so which ones? Current Exercise and Goals   Are you currently involved in any exercise program? Yes No If yes, please list how long and what type of exercises Days a week of weight training and body sculpting 0 1 2 3 4 5 6 7 Days a week of cardiovascular activity 0 1 2 3 4 5 6 7 Type of cardiovascular activity: Have you ever worked with a personal trainer before? Yes No How long did you spend with the trainer? What would you change if you hired that trainer again? What are your long-term personal fitness and health goals? What's currently preventing you from reaching your goals? Additional information we should know about?: | Home | Class Times | The Workouts | Register | Nutrition | Testimonials | Recipes | Contact Us | ©2006. All Rights reserved with Fit and Lean.