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Name_________________________________________ Date of birth:_____________

Address: ______________________________________________________________
_______________________________________________________________
Home Phone: _____________________ Cell Phone: ___________________________
Email address: _________________________________________________________
Do you have any health problems? _____If so, please list: ______________________
______________________________________________________________________
Do you have a history of Heart Disease? _______ Are you diabetic? _______________
Do you have high blood pressure? _______ List any surgeries____________________
_____________________________________________________________________
Please list any medications you are currently taking;____________________________
______________________________________________________________________
______________________________________________________________________
Do you have any recurrent bone, joint or muscle injuries or conditions? _____________
If so, please list: ________________________________________________________
Current Weight________ Height: _________ BMI:______________________________
What is your fitness goal?_________________________________________________
If weight loss, what would be your ideal weight?________________________________
Summarize your current diet_______________________________________________
______________________________________________________________________
______________________________________________________________________
Is there any reason you should not participate in this Boot Camp? ______ Explain:____
______________________________________________________________________
When was your last physical exam?______ Results?____________________________
Are you willing to work out at least 5 days per week outside of bootcamp day? _______
Are you willing to make dietary changes to facilitate your fitness goals? _____________
Do you have a gym membership?_____ If so, where? __________________________
Have you ever worked with a Personal Trainer? ______ When?___________________
Is this your first Boot Camp experience? _____________________________________
How would you rate your current physical fitness on a scale of 1-5, 5 being optimum?
_______________________Why? _________________________________________
Have you ever worked with weight resistance training? _________________________
Can you bring 5 pound weights? ____ Jump Rope?______ Mat?________ Bands? ___

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