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FREE BODYFAT TEST

Fitness or Sports Training

Rehabilitation

Fat Loss

Body Building

Increase Strength

Muscle Tone

Increase Muscle Mass

Health Improvement

Stress Reduction

Other

How many times per week can you work out?

What days of the week and times are best for you?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you smoke?

Yes No

Are you pregnant?

Yes No

Heart Trouble

Bone or Joint Problems

Fainting or Dizzy Spells

Arthritis

High Blood Pressure

Asthma

Low Blood Pressure

Sports Injuries

Back Problems

Epilepsy

Other

Other

Name

Email

Address

Work phone

Cell phone

Best form of contact

---

Home phone

On a scale of 1-10 how important is it for you to achieve your goals?

Do you have any of the following conditions?

Date

D.O.B

Work ph between

Home ph between

Cell ph between

Text

Occupation

What results would you like to achieve?

Signed

Date

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