First Namerequired
Last Namerequired
Date of Birthrequired
Heighttextoptionalno save
Weighttextoptionalno save

Phone (Digits Only)required


Emergency Contact Nametextrequireddb save
Contact Relationshiptextoptionalnot save
Contact Phonenumberrequireddb save

Referraltextoptionalno save

Health History Questionnaire

requireddb save
Have you exercised in the past 6 months?

Type of Exercisetextoptionalno save

requireddb save
Are you dieting?

Nutritional Knowledge?


requireddb save
Do you smoke or have you ever smoked or used smokeless tobacco for a total of 10 years?

Packs of cigarettes smoked per week?textoptionalno save
Alcoholic beverages consumed per week?textoptionalno save

Cups of coffee consumed per day?textoptionalno save
Cans of cola drinks consumed per day?textoptionalno save

Indicate any disease or illness you have

Abnormal or Positive Exercise Stress Test
Back Condition
High Blood Pressure
Low Blood Pressure
Joint Pain
Heart Condition
Nervous Tension
Varicose Veins
Shortness of Breath
If Other, please specifytextoptionalno save

requireddb save
Are you currently taking medication?
Specify what typetextoptionalno save
Dosagetextoptionalno save

When was your last physical exam?dateoptionalno save

Physician’s Name & Phone Numbertextoptionalno save

requireddb save
Have you had a stress test?

Cholesterol HDLtextoptionalno save
LDLtextoptionalno save
Totaltextoptionalno save

requireddb save
Have you ever been hospitalized?
Fortextoptionalno save

requireddb save
Are you pregnant?

Do you have or have you ever had?

Heart Attack or Heart Trouble
Chest Pain or Angina Pectoris
Coronary Bypass or Angioplasty
Abnormal or Positive Exercise Stress Test
Musculoskeletal Limitations
Difficulty Breathing/Shortness of Breath
Knee Problems
A Chronic recurrent or morning cough
Any episode of coughing up blood
Increased anxiety or depression
Swollen, stiff or painful joints
Back Pain (herniated or ruptured disc)
Shoulder Pain
Heart Murmur
Irregular Heart Beat or Rhythm
High Blood Pressure over 145/95
Impaired Circulation
Convulsions or Loss of Consciousness
Diabetes Mellitus
High Blood Cholesterol Level

What Works?

Check off any of the methods or techniques you’ve used in previous attempts tchange your body:

Calorie Restrictive Diet
Weight Loss Drug (i.e. Phen-fen, Redux, Meridia)
Low Fat Diet
High Protein Low Car Diet
A structured eating program based on nutrient % (i.e. 30-40-30%)
Powders or Shakes treplace or supplement meals
Health Food Stores (fat burners, performance aids, etc.)
Aerobics Classes
Weight Training
OTC Pills for Weight Loss Help or Appetite Suppression
Exercise at home (videos, step, etc)
Infomercial Products
Medical Based Weight Loss or Wellness Program
“Just Eating Better” making wiser choices, fruits and vegetables
Your Own Aerobic Exercise Program (biking, walking, etc.)

The question everyone asks in relation to the above so-called “aids” or “solutions” is...

”Does it Work?”

What is the motivation that drives you to want to participate in our program?textoptionalno save

What are your goals and expectations of this program?textoptionalno save

Do you understand that by following the eating program/workout program to the best of your ability you will yield greater results?textoptionalno save

I agree to hold VIP Fitness LLC and all of their employees or agents free from any and all injuries, losses, damages, and liability occurring from my participation in the activity for which I have enrolled. I also agree to be photographed/videotaped and release the use of the photographs/videos for publicity in VIP Fitness LLC publications and other marketing tools.

Date: 3/17/2019

Time: 4:31 PM

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