PAR Form

Waiver Form

Readiness for Change Questionnaire

Social Support Questionnaire

Kitchen Makeover Questionnaire

Meal Worksheet

Physical Activity Readiness

Be sure to click on the "Submit" button when you are finished. All fields are required.

Get HALF OFF NEXT MONTH for referring a friend!
I was referred by:

Date:

First Name:

Last Name:

E-mail:

Address:

City:

Zip Code:

Home Phone:

Work/Cell Phone:

Date of Birth:

Age: Height: Weight:

Which class are you interested in taking?
6am Pan Am Park 9am Pan Am Park 7:30pm

We want more GREAT clients like you. How did you hear about us?
(Please be very specific.)

Please answer all questions accurately and honestly.		Yes	No
1.	Do you have high cholesterol?
2.	Has your doctor ever said that you have heart trouble?
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?
4.	Has your doctor ever told you that your blood pressure was too high, or is currently too high?
5.	Are you over 65 years of age and not accustomed to vigorous exercise?
6.	Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program?
7.	Do you ever feel weak, fatigued, or sluggish?
8.	How many meals do you eat each day?
9.	Do you know how many calories you eat in a day?
10.	Do you eat breakfast?
11.	Are you taking supplements? (vitamins, amino acids, protein shakes, etc.)
12.	Do you crave sugary foods?
13.	Do you need several cups of coffee to keep you going throughout the day?
14.	Do you often experience digestive difficulties?
15.	How long have you been exercising?
16.	Have you reached and maintained your goals?
17.	Are you happy with the way you look and your health?
18.	On a scale of 1 (least) to 10 (most), 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. Why did you decide to come today and not last week, or last month?
22. What are your specific goals?

Name: Commitment to Results: We only work those who want to get serious results. There will be effort involved and it will be challenging at times.

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 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.

Name:

Date: