Lean Body Fit Camp - Before Your First Workout

Full Name *

Email *

Address: *

City: *

Zip: *

Home Phone *

Work Phone *

Date of Birth (MM/DD/YYYY) *

Age *

Height (ft'in") *

Weight (lbs) *

BF% *

How did you hear about us? (Please be specific.) *

1. Do you have high cholesterol? *

Yes

No

2. Has your doctor ever said that you have heart trouble? *

Yes

No

3. Has your doctor ever told you that you have a bone or joint problem (such as arthritis) that has been or may be exacerbated by physical activity? *

Yes

No

4. Has your doctor ever told you that your blood pressure was too high, or is currently too high? *

Yes

No

5. Are you over 65 years of age and not accustomed to vigorous exercise? *

Yes

No

6. Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program? *

Yes

No

7. Do you ever feel weak, fatigued, or sluggish? *

Yes

No

8. How many meals do you eat each day (number only)? *

9. Do you know how many calories you eat in a day? *

Yes

No

10. Do you eat breakfast? *

Yes

No

11. Are you taking supplements? (vitamins, amino acids, protein shakes, etc.) *

Yes

No

12. Do you crave sugary foods? *

Yes

No

13. Do you need several cups of coffee to keep you going throughout the day? *

Yes

No

14. Do you often experience digestive difficulties? *

Yes

No

15. How long have you been exercising? *

16. Have you reached and maintained your goals? *

Yes

No

17. Are you happy with the way you look and your health? *

Yes

No

On a sale of 1 to 10, how serious are you about achieving your goals? *

19. What are you most frustrated with when it comes to getting in shape? *

20. What is your biggest obstacle/s when it comes to getting in shape? *

21. What do you need help on the most? *

22. What are your specific goals?(Be specific as possible) *

ACKNOWLEDGEMENT OF UNDERSTANDING: I have read the Assumption of Risk, Waiver of Liability, provisions in this Agreement and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the Agreement freely and voluntarily and intend, by my signature, that this document be a complete and unconditional release of liability to (Train with Chelsea and those associated with TWC) to the greatest extent allowed by law. I further certify that I have fully read and understand the terms of this agreement and will comply with the contents herein. *

I Accept