Please provide the following contact information:     * Required field.

*First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
*E-mail
*Confirm E-mail

        Please tell us about yourself:

*Date of Birth
*Age
*Sex	Male Female
*Height	feet    inches
*Weight
*What is your frame size?	Small    Medium    Large
Are You Pregnant?	Yes  Not Yet   No
If Yes, Due Date:

        What would you say your level of fitness is?

Beginner
Intermediate
Advanced

        *What is your activity level?

1. Sedentary (Computer/TV all day).

2. Somewhat Active (Errands & Housekeeping).

3. Lightly Active (Walk or other 'light' activity) at least 2x a week.

4. Active (Strength Training/Aerobics--one hour's worth) at least 3x week.

5.  Very Active (Strength Training/Aerobics--one hour's worth) at least 5x a week.

        How many pounds do you want to lose?

 

Are you a smoker?

Yes     No    Quit within the last year

 Please describe your daily activities, i.e.: sitting at a desk, manual labor, heavy housecleaning, chasing toddlers around all day. Please be honest as it will help us in determining what routine would best suit your needs:

 What you do at work (what your job requires physically) What you do at home (housekeeping, computer, etc.) What you do for activities. This is an important part of making your assessment individualized. Thank you! 

Please Note: If you are looking for nutritional info., (i.e. How many calories you should be eating and burning) that is included with the Full Health Assessments.  

          Due to the high volume of submissions, please allow  5-28 days for your FREE assessment to arrive. Thank you for your understanding.--Fit4Jesus Personal Trainer

Enjoy your free assessment and get Fit4Jesus!