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(If form is too complicated please fill out only necessary questions from your point of view)

Please provide the following contact information:

First name             Last name
Sex: Male Female
Street address
City Zip
Work Phone           Home Phone 
Occupation                 Birthdate
Physician's Name        Phone
                        Health Survey

 

Do you have now, or have you had in the past any of the following:
Hystory of cardiac (heart) problems, angina or stroke Yes       No
High or low blood pressure Yes       No
Any chronic illness or condition Yes       No
Muscle or joint pain, disorder, or previous injury Yes       No
Resent surgery (last 12 months) Yes       No
Pregnancy (now or within last 6 months) Yes       No
Back pain or disorder Yes       No
Hernia, or any condition that may be aggravated by lifting wts. Yes       No
Diabetes or thyroid condition Yes       No
Arthritis Yes       No
History of breathing or lung problems Yes       No
Advice from a physician not to exercise Yes       No

    Please explain any question you have answered yes :

* Please consult your physician first before starting this or any exetcise program

                                  Fitness Survey

1 Explain you current exercise program

 
2 By how much would you like to change your current weight ?     (+)          (-)    
3 How many times a week are you currently exercising?        
4 Type of exercise (activity) you are currently engaged in: Anaerobic (endurance):
Anaerobic (wt. bearing exircise) 
5 Please rate your exercise level on a scale of 1 to 5 (5 - indicating very strenuous) for each age range throught you present age:
15 - 20      21 - 30     31 - 40      41 - 50     51 - 60 
6 Current weight     
7 How long have you been exercising on a regular basis?   months      years
8 How much time are you willing to devote to an exercise program ? min/day          day/week
9 Do you feel ypur lifestyle puts you in position of low    low/moderate moderate high/moderate or high stress

 

Please list 3 consecutive days of your eating habits (The more detailed and in depth you are enables us to set up a more precise nutritional program). Please include any snacks in between these meals. 

Day #1
Breakfast:

Time eaten

Lunch:

Time eaten

Dinner:

Time eaten

Day #2
Breakfast:

Time eaten

Lunch:

Time eaten

Dinner:

Time eaten

Day #3
Breakfast:

Time eaten

Lunch:

Time eaten

Dinner:

Time eaten

 

Contact us (Detroit, Michigan)

by E-mail  MAIL  ,or phone (810-751-5076), or go to the application form

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