Get Started

* How did you first learn about Sensible Fitness? Please make a selection... TV Program Health Care Practitioner Seminar/Lecture Educational Professional Friend/Acquaintance Coach Internet I saw the Sensible Fitness van Other

 

* Your Name:

* Email Address:

* Home Phone:

Work Phone:

Mobile Phone:

* Address:

* City:

* State:

* Zip Code:

Emergency Contact

* Name:

* Phone:

* Height (in INCHES):

* Weight:

* Date of Birth: MM/DD/YYYY

* Gender: Select your Gender Female Male

* Profession

* Does your profession require sitting for a large part of the day?  No    Yes

* What are your specific goals?
(i.e. weight loss, gain muscle, toning lower body, etc.)

For general scheduling purposes only (no commitment), what days and times are best for you to visit us? The more specific you can be, the easier it is for us to match you with a trainer.
(i.e. Monday's @ 6pm or after, Wednesday mornings before 10am, Anytime Saturday, etc.)

For general scheduling purposes only (no commitment), how often do you wish to visit us?
(i.e. 3 times p/week for several months, Only a few visits, Once every 2 weeks, etc.))

* How many times per week do you currently exercise?:  days

* How would you describe the intensity?: Moderate (walking, golf) Vigorous (running, soccer)

* How long have you been exercising?: Less than 3 Months 3-12 Months More than 12 Months

* What is the duration of a typical session?:  minutes

* What types of exercise do you perform?

* What level of exercise do you wish to perform with us?: Moderate Vigorous

* Do you currently smoke?: Please Select... No Yes

If yes, how many per day?:

Have you quit smoking in the last 2 years?: N/A No Yes

* Do you often have pains in your heart, chest, or surrounding areas, especially during exercise?  No    Yes

* Do you often feel faint or have spells of severe dizziness during exercise?  No    Yes

* Have you had an attack of shortness of breath that came on after you had stopped exercising?  No    Yes

* Have you been awakened at night by an attack of shortness of breath?  No    Yes

* Do you experience swelling or accumulation of fluid in and around the ankles?  No    Yes

* Do you often get the feeling that your heart is racing or skipping beats, either at rest or during exercise?  No    Yes

* Do you regularly get pains in your calves or lower legs that are not due to soreness or stiffness?  No    Yes

* List any diseases (including high blood pressure) that a doctor has told you that you have (Enter NONE if you have no known diseases)

* Have you ever been told that you have diabetes?  No    Yes

If yes, what type?: N/A IDDM NIDDM

How long have you had it?: years

* List any medications that you take on a regular basis (Enter NONE if you take no medications)

Vitals Information (only enter if known)

Total Cholesterol:

Blood Pressure:

HDL Cholesterol:

Triglycerides:

Questions for Women only

Is it possible you are pregnant?  No    Yes

Have you experienced menopause before the age of 45?  No    Yes

If yes, are you currently taking hormone replacement therapy?  No    Yes

* Has your father, mother, brother, or sister had a heart attack, or suffered, or died from cardiovascular disease before the age of 65?  No    Yes

If yes, Female or Male?: N/A Female Male

How old were they when diagnosed?: years