Fitness Program Request

Please submit the following form for a consultation report.

General Questions
Has your doctor indicated that you have a heart condition?	Yes          No
Has your doctor ever said that your blood pressure was too high?	Yes          No
Do you have any bone, back or other joint condition that may be aggravated by exercise?	Yes          No
Do you suffer from epilepsy or asthma?	Yes          No
Do you suffer from diabetes?	Yes          No
Are you pregnant?	Yes          No
Are you taking any prescribed medication that may affect your ability to exercise?	Yes          No
Do you smoke?	Yes          No
Is there any reason not mentioned above why exercise is not suitable for you? (Please specify)
Goal Setting
What is/are long term goal(s) that can be accomplished through fitness?
When do you want to achieve your goal?
What will be the benefit if you accomplish these goals?
What is the most realistic time of the day to do your activities?	Early morning Morning Midday/Afternoon Evening
How many times a week can you participate in your activities?	times a week.
Body Specifics Please fill out as accurately as possible
Weight
Height
Bloodpressure
Personal Details
Full Name:
Age:
Email:
Contact Number:
Turing Test: Enter the letters you see