General InformationName* First Last Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth Year Month Day Gender Male Female Emergency ContactsNameRelationPhone Health HistoryHistory of Health IssuesCheck all that apply Heart problems, chest pain, stroke Chest pain during physical activity High blood pressure Diabetes Type 1 or 2 Heart Murmer History of breathing or lung problems Dizziness or Fainting Thyroid, Renal or Liver Disease Osteoporosis Muscle, Joint or Back Disorder Hernia Any Recent Surgeries (last 12 months) Pregnancy (now or within 3 months) Smoker Any chronic Illness or condition Other Issue(s) History of Health Issues (Details)Please describe the issue(s) you checked above.History of Health Issues (Other Issues)Please describe what the other issue(s) are.List any medications you're takingNameBrand Exercise HistoryYour physical activityIn a few sentences, tell us about your past physical activityHS or College Athletics?Positive or Negative feelings about exercise?Good or Bad Exercise Experiences?Any specific physical activities you've enjoyed?Athletic AbilitySelf Rate: 1:lowest - 5:highest 1 2 3 4 5 CoordinationSelf Rate: 1:lowest - 5:highest 1 2 3 4 5 CardiovascularSelf Rate: 1:lowest - 5:highest 1 2 3 4 5 Muscle StrengthSelf Rate: 1:lowest - 5:highest 1 2 3 4 5 FlexibilitySelf Rate: 1:lowest - 5:highest 1 2 3 4 5 Current LifestyleCurrent Occupation Physical activity at workUsual Leisure ActivitiesCurrent GoalsWhat specific goals are you looking to accomplish?Physical Activities you currently enjoyWhat do you want Physical Activity to do for you?Check all that apply Improve Cardiovasular Weight Loss Improve Stress and Mood Improve Flexability Improve Strength Improve Energy Level Improve Performance for a specific Sport Diet & NutritionDo you have a healthy diet? Yes No Approx how many calories do you consume daily? List any supplements you're takingSupplementBrand List any shake/ meal replacements you're taking What's a bad eating habit you're willing to change?Your Daily DietList out what your average daily diet looks like. Please include breakfast, lunch, dinner and any snacks throughout the dayNameTimeUsual Diet EmailThis field is for validation purposes and should be left unchanged.
