Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone number *Career *What's going on in your life right now? (Health, relationships, business, career, etc.) *What are your goals and what vision do you have for your future? *Why are these goals important to you and what would it mean for you to achieve them? *What obstacles stand in your of achieving these goals? *How committed are you to achieving these? (1 - Not interested at all, 10 - I would do anything!) Selected Value: 1 Have you had any major injuries or surgeries? If so, please describe them in full.Have you ever worked with a personal trainer before? If so, what was your experience?Are you currently taking any medications? If so, please list them.Do you smoke? *YesNoOccasionallyHow frequently do you consume alcohol? *NeverOnly on special occasionsMultiple times a weekDailyHas your doctor ever said that you have a heart condition or high blood pressure? *YesNoDo you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity? *YesNoDo you lose balance because of dizziness or have you lost consciousness within the past 12 months? *YesNoDo you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament or tendon) problem that could be made worse by becoming more physically active? *YesNoIf you selected yes above, please list condition(s):Has your doctor ever said that you should only do medically supervised physical activity? *YesNoSubmit
