Myofitness Online Personal Training

Online Personal Training
Information Form

Why wait? You can get started with Online Personal Training right away! Just fill out the form below and we'll get in touch with you promptly to iron out all the details. Or if you prefer, you can give us a call and request that the forms be sent to you via land mail.

name:
address:
city, state, zip:
phone:
email:
business phone:
fax:
physician's name
physician's phone
does your physician know you are participating in this exercise program?
are you taking any medications or drugs?
if you answered "yes" above, list any medications or drugs you are currently taking
describe your current exercise program
list any hobbies you have
how did you hear about Myofitness?

 

age .....................height .............................weight  

do you now or have you in the past had any of the following:
history of heart problems, chest pain, or stroke
increased blood pressure
any chronic illness or condition
difficulty with physical exercise
advice from physician not to exercise
recent surgery (last 12 months)
pregnancy (now or within last 3 months)

respiratory problems, lung disease, or difficulty breathing

muscle, joint, or back disorder, or any previous injury still affecting you
diabetes or thyroid condition
cigarette smoking habit
obesity (more than 20% over ideal body weight)
increased blood cholesterol
history of heart problems in immediate family
hernia or any condition that may be aggravated by lifting weights

if you answered "yes" to any of the above, please explain:

What is your purpose for participating in this program?
What do you hope to achieve?

 


MyoFitness
@
Alexander's
in
Harmarville