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PERSONAL INFORMATION |
| Name: * |
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| Address: * |
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| Apartment: |
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| City: * |
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| State: * |
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| Zip Code: * |
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| Do you live at Post Riverside? * |
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| Available for training in the Atlanta area? * |
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| Home Phone: * |
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| Work Phone: * |
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| Cell Phone: * |
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| E-mail Address: * |
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| Which is the best way to contact you? * |
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| Date of Birth (mm/dd/yyyy): * |
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| Height: Feet: * |
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| Height: Inches: * |
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| Current Weight: * |
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| Occupation: * |
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| Hours worked per week: * |
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GOALS AND
BACKGROUND INFORMATION
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| What do you want to accomplish? * |
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| What are your outcome goals over the next 12 weeks? * |
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| How often did you you work out in the past? |
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Cardio: |
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Resistance Training: |
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Do you * |
with this statement? |
| How many meals do you eat per day? * |
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| Do you eat breakfast? * |
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| Typically, do you eat after 8pm? * |
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| If yes, what do you usually eat? |
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| Do you read food labels? * |
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| How often do you eat out (restaurants, work, on the road, etc.)? * |
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DIETING
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| Have you ever been on a diet? * |
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| How many diets have you been on in the last two years? * |
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| Describe any diets you have been on: |
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| What were the results of the dieting: |
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| Did you go to a commercial weight loss service (Jenny Craig, WW, Diet Center, Etc.)? |
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| Did you follow a diet from a book or article? |
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| If yes, which one? |
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ADDITIONAL
INFORMATION
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| Describe your typical work week (Include hours per week, business trips, etc.): * |
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| How much free time do you typically get each week and what do you usually do with that time? * |
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| How many hours of sleep do you get each night? * |
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| Do you drink water? * |
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| How many glasses of water do you drink each day? |
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| How much caffeine do you drink each day? * |
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| Would you have a problem with doing your cardio exercises on your own? * |
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| Can you allocate five days (approximately 1 hour per day) a week to exercising? * |
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| Have you been with a trainer before? * |
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| What are you looking for in a trainer? * |
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| What type of medical history do you have? * |
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| Is there anything that will prevent you from exercising? * |
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| What injuries or limitations do you have? |
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| What time of day is the best for you to train? * |
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| When do you prefer to work out? * |
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| Desired # of workout sessions per week: * |
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| When do you want to start training?: * |
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| What kind of training do you prefer? * |
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| How did you hear about my program? * |
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| If you heard about my program from someone (friend, client, etc.) please let me know who: |
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| * Required |
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