* Required fields
Name *
E-mail Address *
Phone Number *
Work Phone *
Address *
Best time to call *
Age *
Gender *
Select
Male
Female
Height *
Weight *
Do you have a present, diagnosed disease, i.e. heart disease, lung disease, cancer, metabolic diabetes? If so, please explain. *
Has your doctor ever said that you have a heart condition & that you should only Perform physical activity recommended by a doctor *
Select
Yes
No
Do you feel pain in your chest when you perform physical activity? *
Select
Yes
No
In the past month, have you had chest pain when you are not performing any physical activity? *
Select
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Select
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Select
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Select
Yes
No
Do you have a history of heart disease or high blood pressure in your family? If so, please explain. *
Do you have any injuries or physical limitations? If so, what are they? *
What is your current activity level? *
Select
Sedentary: little or no exercise
Lightly Active: 1-3 times/week
Moderately Active: 3-5 times/week
Very Active: 6-7 times/week
Extremely Active: very active 2x/day
How much stress do you experience on a daily basis? *
Select
Little or No Stress
Moderate Amount of Stress
A Lot of Stress
More Than I Can Handle
Do you smoke cigarettes? *
Select
Yes
No
Does Your Occupation Require Extended Periods of Sitting? *
Select
Yes
No
Women: Are you pregnant?
Select
Yes
No
Are you currently taking any nutritional supplements, i.e. creatine, protein, etc.? If so, please explain. *
Have you worked with a personal trainer before? If so, with whom? *
What is your fitness background - How long have you been working out? *
Please describe your daily schedule? *
How many days per week do you wish to train? *
Days you prefer to workout *
Best time during the day to workout *
What are your goals - what do you wish to get out of training with Corey? *
Do you currently belong to a gym or health club? If so, which one(s)? *
Do you own any exercise equipment? If so, please list all equipment *
