ࡱ> hjg @ Jbjbjʚʚ "bTTTT@@@@$S)h,X71r(t(t(t(t(t(t($*R -(u37(TTX )w$w$w$4T8Xr(w$r(w$w$V''  4{@n'r(#)0S)v',-n-'TTTT'8-'w$(( < s!< Online Personal Training Questionnaire Thanks for taking the time to fill out this online questionnaire. You are filling out this questionnaire so that I can create your custom online training program. Weve also determined that you are a very busy and motivated individual so you are a great candidate for Online Personal Training. My most successful online clients are motivated, determined and know what it takes to reach their goals. Sounds like I can add you to the list! Once youve completed the questionnaire, save it to your computer. Then attach it to an email (along with the other required documentation) and send it to me at  HYPERLINK "mailto:GetHealthyWithJenn@msn.com" GetHealthyWithJenn@msn.com. It wont take long to generate your Online Program, so you will literally be up and running within 24-hours! Congratulations on taking the next step to your health! Name:  FORMTEXT       Date:  FORMTEXT       Address:  FORMTEXT       City, State, Zip:  FORMTEXT       Phone: Home  FORMTEXT       Cell  FORMTEXT       Email:  FORMTEXT       Best method/times to contact you:  FORMTEXT       Birth date:  FORMTEXT       (mm/dd/yyyy) Age:  FORMTEXT       Current Weight:  FORMTEXT       Goal Weight:  FORMTEXT       Current Body Fat %:  FORMTEXT       (if known) Goal Body Fat %:  FORMTEXT       (if known) Height:  FORMTEXT       Goal:  FORMTEXT       Trouble spots:  FORMTEXT       Current Activity Level (including exercise, recreational sports and profession):  FORMTEXT       Do you currently participate in a cardio program?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If so, what type of cardio do you like to do?  FORMTEXT       Do you currently participate in a strength program?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If so, do you prefer machine weights or free weights or both?  FORMTEXT       Do you currently participate in a stretching program?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Do you exercise at  FORMCHECKBOX  the gym or  FORMCHECKBOX  home or  FORMCHECKBOX  both? If home, what type of equipment is available?  FORMTEXT       If you have selected that you will exercise at home, I would recommend purchasing a stability ball, resistance bands, and a set of light and heavy dumbbells. All of this can be purchased from your local sporting goods store, Target or Walmart, or online at  HYPERLINK "www.Exercise-On-The-Net.com" www.Exercise-On-The-Net.com for less than $50. Do you prefer group fitness classes, working out with a friend or alone?  FORMTEXT       Please specify the amount of exercise in &'(  } ~ ƷƷzf[PF<hxOJQJ^JhsOJQJ^Jhx5OJQJ^JhKN5OJQJ^J'h;h 0J6CJOJQJ^JaJ2jh;h 6CJOJQJU^JaJ&jh 6CJOJQJU^JaJh 6CJOJQJ^JaJhY&6CJOJQJ^JaJ#hY&hY&6CJOJQJ^JaJhY&6OJQJ^JhY&56OJQJ^JhY&hY&56OJQJ^J'( } ~  J H zPRfhgds$a$gd $a$gdY&$a$gdY&JJ     " 6 8 : D F H J X Z \ ^ r t v 񻱣wmYmwm'jhlBh;zOJQJU^Jhm&[OJQJ^JhR#hm&[5OJQJ^J'j{hlBh;zOJQJU^JhsOJQJ^JhR#hs5OJQJ^Jhc9OJQJ^JhR#OJQJ^JjhCKOJQJU^J'jhlBh;zOJQJU^JhlBOJQJ^JjhlBOJQJU^J"        4 6 8 B D F H R T X Z n ԼxdxZZhR#OJQJ^J'jKhlBh;zOJQJU^J&jhlBOJQJU^JmHnHu'jhlBh;zOJQJU^Jh*UhlB6OJQJ^JhR#hm&[5OJQJ^Jhm&[OJQJ^JjhCKOJQJU^JjhlBOJQJU^J'jchlBh;zOJQJU^JhlBOJQJ^J!n p r | ~   ",.2JLRTXݿݝݝqݝ]ݝSqh[#OJQJ^J'jhlBh;zOJQJU^JhR#hs5OJQJ^JhsOJQJ^J'j3hlBh;zOJQJU^JhlBOJQJ^JhlBhlB6OJQJ^Jhm&[OJQJ^JhR#OJQJ^J&jhlBOJQJU^JmHnHujhlBOJQJU^J'jhlBh;zOJQJU^JXZ\prt~:<>R謢vb芢'jhlBh;zOJQJU^J'jhlBh;zOJQJU^JhR#OJQJ^JhR#hs5OJQJ^JhsOJQJ^Jh[#OJQJ^J&jhlBOJQJU^JmHnHu'jhlBh;zOJQJU^JhlBOJQJ^JjhlBOJQJU^Jh=7OJQJ^J"RTV`bdxz "ݿݿ{ݿmݿYݧKhc9hs5OJQJ^J'jihlBh;zOJQJU^JhlBhs6OJQJ^J'jhlBh;zOJQJU^JhR#OJQJ^JhR#hs5OJQJ^JhsOJQJ^JhlBhlB6OJQJ^JhlBOJQJ^J&jhlBOJQJU^JmHnHujhlBOJQJU^J'j}hlBh;zOJQJU^J"$(*>@BLNPRlnrt$8<>@TެޢԀެrhZPh*UOJQJ^Jjh*UOJQJU^Jh&kOJQJ^Jh*Uhs5OJQJ^J'jUhlBh;zOJQJU^Jhc9hs5OJQJ^JhqOJQJ^J&jhlBOJQJU^JmHnHu'jhlBh;zOJQJU^JhlBOJQJ^JjhlBOJQJU^JhR#OJQJ^JhsOJQJ^JTVXbdfhݿq[qJ6J'j h*Uh;zOJQJU^J!jh*UhlBOJQJU^J*jA hlBh;z5OJQJU^JjhlB5OJQJU^Jhc9hq5OJQJ^Jhc9hs5OJQJ^JhlB5OJQJ^Jh*UhlBOJQJ^JhsOJQJ^Jh&kOJQJ^J&jh*UOJQJU^JmHnHujh*UOJQJU^J'jh*Uh;zOJQJU^J"$Zf~4´xnaVVFVjhV5OJQJU^JhV5OJQJ^Jh*UhVOJQJ^Jh&kOJQJ^JhqOJQJ^J&jhlBOJQJU^JmHnHu'j) hlBh;zOJQJU^JhlBOJQJ^JjhlBOJQJU^Jhc9OJQJ^JhlB6OJQJ^JhlBhq6OJQJ^Jhc9hs5OJQJ^Jh*UhlBOJQJ^Jh$l.02 > >t>l?n?*@,@@@`A4BgdS-gd/gds468:@B^`bjlz±ssi[Q=['j h*Uh;zOJQJU^Jh*UOJQJ^Jjh*UOJQJU^Jhc9OJQJ^Jh*Uh*U6OJQJ^Jh*Uhq6OJQJ^Jhc9hs5OJQJ^J'j h*Uh;zOJQJU^J!jh*UhVOJQJU^Jh*UhVOJQJ^JhV5OJQJ^JjhV5OJQJU^J*j hVh;z5OJQJU^JVZ~ǼwcwXMC9hsOJQJ^Jh*UOJQJ^Jh&k5OJQJ^Jhq5OJQJ^J'jq h*Uh;zOJQJU^J!jh*Uh*UOJQJU^J*j h*Uh;z5OJQJU^Jjh*U5OJQJU^Jhc9hs5OJQJ^Jh*U5OJQJ^Jh*Uh*UOJQJ^JhqOJQJ^Jjh*UOJQJU^J&jh*UOJQJU^JmHnHu"$&*@B^`bfnvx *,.ʇ}iU&jh*UOJQJU^JmHnHu'jAh*Uh;zOJQJU^Jhc9OJQJ^Jhc9hs5OJQJ^J'j h*Uh;zOJQJU^Jh*UhsOJQJ^J'jY hCKhT OJQJU^JhsOJQJ^J'j h*Uh;zOJQJU^Jjh*UOJQJU^Jh*UOJQJ^J.268޸ޞހsf\ND0'jh*Uh;zOJQJU^Jh*UOJQJ^Jjh*UOJQJU^JhOJQJ^Jh*UhsOJQJ^Jh*Uh*UOJQJ^JhsOJQJ^J'h*Uh*U0J6CJOJQJ^JaJ2jhS-h;z6CJOJQJU^JaJ,jh*Uh*U6CJOJQJU^JaJh$6CJOJQJ^JaJ#h*Uh*U6CJOJQJ^JaJh=76CJOJQJ^JaJ<<<<<<`======>> > >ƸyeyQyGh/OJQJ^J&jhS-OJQJU^JmHnHu'j&hS-h;zOJQJU^JjhS-OJQJU^JhS-OJQJ^Jh*UOJQJ^JUh*UhsOJQJ^JhS-hs5OJQJ^JhS-h*U5OJQJ^Jh*Uh*UOJQJ^JhsOJQJ^J&jh*UOJQJU^JmHnHujh*UOJQJU^Jterms of number of days per week, time of day, amount of time per workout that you feel will fit in with your lifestyle. Include any days of the week that are your preferred  exercise days or any days that are your preferred  rest days .  FORMTEXT       Accurately rate your professional activity level:  FORMCHECKBOX  Sedentary  FORMCHECKBOX  Moderately Active  FORMCHECKBOX  Active  FORMCHECKBOX  Very Active Grade your current eating habits on a scale of 1 to 10 (10 being best):  FORMTEXT       Are you willing to change your current eating habits?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Which of the following statements best describes you?  FORMCHECKBOX  I can eat anything I want and not gain weight. I have a very hard time gaining weight.  FORMCHECKBOX  I can lose or gain weight by adjusting my activity level and eating habits.  FORMCHECKBOX  I find it very hard to lose weight. I gain weight very easily and have to watch everything I eat. Health History Do you have a history of heart problems, chest pain or stroke?  FORMTEXT       Do you have a family history of heart problems?  FORMTEXT       Do you have high blood pressure?  FORMTEXT       Do you have any chronic illness or condition?  FORMTEXT       Do you have difficulty with physical exercise?  FORMTEXT       Have you recently had surgery?  FORMTEXT       Are you, or have you been pregnant within the last 3 months?  FORMTEXT       Do you have a history of breathing or lung problems or do you smoke?  FORMTEXT       Do you have muscle or joint problems or any injuries?  FORMTEXT       Do you have Diabetes or a thyroid condition?  FORMTEXT       Do you ever feel weak, fatigued, or sluggish?  FORMTEXT       Any medications I need to be aware of?  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