Gym trial

GYM registration

STUDENT INFORMATION

Please complete all REQUIRED fields marked with an asterisk (*) (Student information only) and must mention Student last name, Student First name

Required *

Your Name

Your Email Address

Your Phone Number

Height

Weight

What's the activity level at your job?

None (seated only) Moderate (light activity such as walking) High (heavy labor, very active)

Please list the physical activities that you participate in outside of the gym and outside of work:

If you are on any medications, please list them.

What additional therapies are being undertaken for the given injury and health problem(s)?

Are you a current cigarette smoker?

Yes No

Your current diet could be best characterized as:

Low-fat Low-carb High-protein Vegetarian/Vegan No special diet

What following goals does best fit in with your goals?

Improved health Improved endurance Increased strength Increased muscle mass Fat loss

Are you currently excersising regulary (at least 2x per week)?

Yes No

Have you trained with a personal trainer before?

Yes No

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