No Memberships         Free Equipment         No Trips to the Gym         No Waiting for Equipment         Prices Match any Gym         No Dragging your kids to Gyms         Free Comprehensive Fitness Assessment         No Insecurities         No Hassles         NOGYM!

Whether you were directed to this form by an associate and have your Free Assessment (which includes: Heart Rate Training Zones, Blood Pressure, Body Mass Index, Body Fat %, Cardio Assessment and circumference measurements) — set up or you just came across our web site and reside in the area we service please fill out the questionnaire to the best of your ability, and click "Submit Form" at the bottom of the page. Please ensure that you answer all questions.

All information is kept strictly confidential, as outlined in the PRIVACY STATEMENT.


GENERAL INFORMATION
First Name
Last Name
Street Address 1
Street Address 2
City
State
Zip Code
Phone
E-mail
Sex FEMALE MALE
Age
PHYSICAL ACTIVITY READINESS QUESTIONAIRE (Please answer YES or NO)
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES NO
2. Do you feel pain in your chest when you do physical activity? YES NO
3. In the past month, have you had chest pain when you were not doing physical activity? YES NO
4. Do you lose balance because of dizziness or do you ever lose consciousness? YES NO
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
 YES NO
6. Is your doctor currently prescribing drugs( for example, water pills ) for your blood pressure or heart condition YES NO
7. Do you know of any other reason you should not do physical activity? YES NO
* IF YOU ANSWERED YES TO ONE OR MORE QUESTIONS: Talk with your doctor by phone or in person before you start becoming much more physically active.
HEALTH HISTORY (Please answer YES or NO)
Has your physician advised you not to exercise? YES NO
Does your physician know you are participating in this exercise program? YES NO
Are you taking any medications or drugs? YES NO
If yes, please list medication, dose and reason:
Describe any physical activity you do somewhat regularly?
DO YOU HAVE NOW, OR HAVE YOU HAD IN THE PAST (Please answer YES or NO)
1. History of heart problems, chest pain or stroke YES NO
2. Increased blood pressure YES NO
3. Any chronic illness or condition YES NO
4. Difficulty with physical exercise YES NO
5. Recent surgery (last 12 months) YES NO
6. Pregnancy (now or within last 3 months ) YES NO
7. History of breathing or lung problems
 YES NO
8. Muscle, joint or back disorder, or any previous injury still affecting you YES NO
9. Diabetes or thyroid condition YES NO
10. Cigarette smoking habit YES NO
11. Obesity ( more than 20 percent over ideal body weight )
 YES NO
12. Increased blood cholesterol YES NO
13. History of heart problems in immediate family YES NO
14. Hernia or any condition that may be aggravated by lifting weights. YES NO
Please explain any “yes” answers:
YOUR EXERCISE HABITS & AVAILABILITY
1. How often do you perform moderate exercise?
2. How would you rate your current fitness level? Scale of 1-10.
3. List any other factors which might affect your safe participation in a fitness program.
4. List your personal fitness goals. (weight loss, tone, strength goals….)
5. Do you have 1-3 hours a week available for a fitness program? YES NO
6. How did you hear about us?
7. Are you a member of a local gym? If yes, where?
8. Have you ever worked out with a fitness trainer before? YES NO
9. Do you have a few square feet of space in your home where you can perform physical exercise? YES NO
ANYTHING ELSE WE SHOULD KNOW? COMMENTS?

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