DATE:

NAME: 
ADDRESS: 

AGE:
BIRTH DATE:

HEIGHT:
WEIGHT:

HOME PHONE:
WORK PHONE: 

E-MAIL ADDRESS:


          ****** CURRENT STATUS ******


1. I am currently; active __  moderately active __ sedentary __

2. Do you currently follow a regular exercise program?

3. If so what types of exercises do you do?

4. How many times a week?

5. How long is each exercise session?

6. What exercises do you enjoy the most?

7. What exercises do you enjoy the least?

8. Can you workout alone __  or do you need group motivation? __

9. Have you ever lifted weights before?

10. What are your thoughts on weight training?

PLEASE ANSWER THE FOLLOWING: POOR, FAIR, GOOD, OR EXCELLENT.

11. How is your energy level?

12. How is your strength?

13. How is your flexibility?

14. How is your endurance?

15. How do you sleep at night?


          ****** DIET ******


PLEASE ANSWER THE FOLLOWING: ALWAYS, USUALLY, SOMETIMES, OR NEVER.


1. Do you eat breakfast?

2. Do you eat lunch? 

3. Do you eat dinner?

4. Do you eat between meals?

5. Do you eat before bed?

6. Do you eat "junk" foods?

7. Do you eat fruits?

8. Do you eat vegetables?

9. Do you eat grain products?

10. Do you eat pastry products?

11. Do you eat red meat?

12. Do you use table salt?

13. Do you use table sugar?

14. Do you smoke?

15. Do you drink alcohol & in what form?

16. Do you use recreational drugs?
    If "Yes" please list:


17. Do you use supplements?
    If "Yes" please list:


18. Do you use drugs to enhance sports performance?
    If "Yes" please list:


          ****** MEDICAL ******


1. Who is your personal physician?

2. When was your last physicial examination?

3. Are you currently under a doctor's care?

4. If you are, for what reasons?


PLEASE ANSWER THE FOLLOWING: YES OR NO, AND EXPLAIN ANY YES ANSWERS.


5. Do you have any food allergies?


6. Do you have high blood pressure?


7. Is there a history of high blood pressure in your family?


8. Do you have heart disease?


9. Is there a history of heart disease in your family?


10. Are you a diabetic?


11. Is there a history of diabetes in your family?


12. Has your doctor advised you to lose weight?


13. Are you currently on a diet?


14. Are you currently on any prescription medications?


15. Have you recently under-gone surgery?


16. Have you recently been hospitalized?


17. Have you recently been seriously ill?


18. Have you recently suffered any serious injuries?


19. Do you experience stomach distress, gas or heartburn?


20. Do you experience lower back pain or stiffness?


21. Do you experience other muscle or joint pain or stiffness?


22. Do you consider yourself to be under a great deal of stress?


          ****** GOALS & EXPECTATIONS ****** 


1. What organized sports are you involved in?

2. How often do you participate?

3. What are your sports performance goals?

4. In what ways would you like to improve your health?

5. In what ways would you like to improve your appearance?

6. What aspects of your physique do you fell need the most work?

7. What do you feel is your ideal weight for your height and bone structure?

8. What dietary habits are you hoping to change?

9. How much time a week are you willing to commit to your fitness goals?

10. How many times a week do you want to workout?


          ****** ON THE BACK OF THESE SHEETS, WRITE THE FOLLOWING... ******


a.) List everything you eat and drink for 7 days, including water and alcohol,
and the time of day each meal or snack was ingested.


b.) List any medical problems injuries or limitations you may have, as well as
anything else you feel could be pertinent to your workouts or your progress.


c.) List all of the equipment that will be available to you where you will be
training if not at The Dungeon. (If necessary ask a gym employee to help with
this list.)


d.) And finally tell me about your training goals.


          ****** RELEASE ******


Upon the execution of these forms, I hereby testify that all of the above
information is true and correct to the best of my knowledge. I also hereby
release any claims for damages of any kind or nature whatsoever that I,
my heirs, and assigns may have against the sponsor(s) or instructor(s) of
the above named program for any and all injuries suffered by me during, or
as a result of said program. 

I further attest and verify that I am physically fit and able to undertake
said program.


SIGNED: 


DATE:


Signature of parent or guardian if above named is under 18 years of age:


SIGNED:


DATE: