EmailMeForm
What services you are interested in? (i.e. private or semi-private training, nutrition, etc.)
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Contact Information
How did you first learn about Sensible Fitness?
Please Select
TV Program
Health Care Practitioner
Internet
Facebook/Social Media
Friend/Acquaintance
Other
Your name
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First
Last
Email
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Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Best Telephone Contact:
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In case of emergency:
Emergency Contact Name
First
Last
Emergency Contact Phone
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Personal Information:
Height (in INCHES):
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Weight
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Date of Birth
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MM
/
DD
/
YYYY
Gender
Please Select
Female
Male
What are your specific goals? (i.e. weight loss, gain muscle, toning lower body, etc.)
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Current Activity Information
Are you currently exercising? If so, how long?
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Please Select
Not currently exercising
Less than 3 Months
3-12 Months
More than 12 Months
If exercising, what types of exercise do you perform?
Health Information
Has a doctor ever said that you have a medical condition and that you should only perform physical activity recommended by a doctor?
*
Please select
Yes
No
Do you feel pain in your chest when you perform physical activity?
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Please select
Yes
No
In the past month, have you had chest pain when you were not performing any physical activity?
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Please select
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Please select
Yes
No
Do you have ache, pain, medical condition, or past orthpedic issue (rotator cuff, knee pain, low back issues, etc.) that could be made worse by a change in your physical activity?
*
Please select
Yes
No
If you answered yes to the above question, please tell us about your issue(s).
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
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Please select
Yes
No
If you answered yes to the above question, please tell us about your issue.
