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		Please take a few minutes to fill out the following questionnaire. All client information is strictly confidential and never shared with anyone else. Contact Information Name Email Address Street Address City State Zip Code The best number to reach you Personal Information Date of Birth Sex Male Female Height Weight Weight 1 year ago Estimated Weight at 21 years of age 1. Do you have any physical or medical conditions that would limit you from engaging in a safe exercise program? Include any surgery you may have had. Yes No If yes, please explain in detail: 2. List any medications you are currently taking: Lifestyle 3. Occupation: 4. How many hours do you work per week? 5. How do you spend most of your time at work? sitting at desk walking driving standing carrying loads other: 6. Do you smoke? Yes No If yes, how many per day: 7. Did you ever smoke? Yes No If yes, when did you quit? 8. Indicate your daily stress level on a scale of 1-10 (10 being very stressed): 9. Indicate your energy level on a scale of 1-10 (1 being low energy): Physical Activity 10. What is your favorite physical activity? How often do you do it? 11. How many times per week do you engage in moderate or strenuous exercise for at least 20 minutes? Describe: How long have you been doing this? 12. Have you ever begun an exercise program and then stopped? Yes No If yes, when Why did you stop? Availability for Workout 13. How many times per week do you want to train with Pedro? Please indicate the exact times and days you are available to train: 14. Please provide a day and time which would be convenient for you to schedule your initial Fitness Evaluation. Alternative day and time. 15. What would you like to achieve through participation in a fitness program? 16. In order to match you with the trainer who has the personality and the right experience to help you achieve your goals, please indicate what you are looking for in a personal trainer? I heard about Pedro from:	Please send us your profile and automatically win a week of FREE GYM