Personal DetailsFirst Name *Surname *Sex *MaleFemaleDate of Birth *Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmail Home Phone Mobile Occupation Emergency ContactsName Number Relationship Name Number Relationship Medical InformationMedical Issues Do you have, or previously suffered from any of the following:High blood pressureAsthmaHeart condition/strokeEpilepsyDiabetesDizziness, fainting or headachesMedical Issues (Other) Any other condition/prior surgery not listed above, please give details.Are you currently taking any prescribed medication? YesNoIf yes, please give details Do you have any conditions or injuries that may affect your ability to train? YesNoIf yes, please give details Are you pregnant or have given birth within the last 6 months? NoYes Lifestyle & Current exercise habitsWhat is your training background/experience (include type of training) Are you currently exercising regularly? YesNoFrequency (sessions per week) 12-33-45+Do you smoke? NoYes Goals and Desired OutcomesWhat do you hope to achieve by working with me? Reduce body fatGain strengthGain muscle definitionGeneral tone upMore energyImprove self confidenceImprove overall fitnessOther What do you expect from me as your trainer/coach? Short term goal (8-12 weeks) Long term goal (6-12 months) How would you like to see yourself? Why is it important for you to achieve your goal? Training Times Please indicate available time preference to devote to trainingMon 5amMon 9amTue 6amTue 5pmWed 5amWed 9amThur 6amThur 5pmFri 5amFri 9amSat 6amNotes Disclaimer & FeedbackHow did you hear about me? Everything that I have provided is true and correct and I will notify my training if anything changes *Yes VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
