TRAINER Registration

Today's date *
Today's date
Name *
Address *
Phone *
How physical is your work?
Emergency Contact
Emergency Contact's Phone Number *
Emergency Contact's Phone Number
What are your top three fitness goals?
establish exercise habit, improve cardiovascular fitness, increase strength and endurance, improve flexility, train for a running event (5K, 10K), Sports conditioning, injury rehabilitation, improve muscle tone, increase muscle mass, other
What are your top three health goals?
improve energy level, improve nutrition, feel better overall, achieve balance in my life, reduce body fat, control cholesterol, control blood pressure, stop smoking, reduce stress, prevent or control diabetes, other
Body composition and other information
Date of Birth *
Date of Birth
If you want to lose weight, how much would you like to lose?
Physical Activity Readiness Questionnaire
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Do you know of any other reason why you should not do physical activity? *
I have read, understood and completed the above Physical Activity Readiness Questionnaire. Any questions I had were answered to my full satisfaction. *