Personal Fitness Trainer Online Registration

* First Name
* Last Name
* Birth Date = d-m-y
* Height - cm or ft / in
* Weight - kg or lbs

Female  Male * Gender     Mother Father No Kids * Parent

* Your Job
* Describe Your Work
* Hobbies - Interests

* E-mail Address
* Telephone Number
   Fax - optional

Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua / Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia / Herzegovina Botswana Bouvet Island Brazil Br. Indian Ocean Ter. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Isls. C. A. R. Chad Chile China Christmas Island Cocos (Keeling) Isls. Colombia Comoros Congo Congo, Dem. Rep. Cook Isls. Costa Rica Croatia Cuba Cyprus Czech Rep. Denmark Djibouti Dominica Dominican Rep. East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Isls. Faroe Isls. Fiji Finland France France, Metropolitan French Guiana French Polynesia Southern Ter.(Fr.) Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard / McDonald Isls. Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Isls. Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Isls. Norway Oman Pakistan Palestine Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia / S. Sandwich Isls.  Saint Kitts / Nevis Saint Lucia Saint Vincent / Grenadines Samoa San Marino Sao Tome / Principe Saudi Arabia Senegal Serbia / Montenegro Seychelles Sierra Leone Singapore Slovak Rep. Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre / Miquelon Sudan Suriname Svalbard / Jan Mayen Isls. Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad / Tobago Tunisia Turkey Turkmenistan Turks / Caicos Isls. Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States U.S. Minor Outlying Isls. Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Isls. (Br.) Virgin Isls. (U.S.) Wallis / Futuna Isls. Western Sahara Yemen Zambia Zimbabwe * Where You Live

* Postal Address

When did you last exercise regularly or participate in sports activities?
   Never ^{please go here}              Approximately

Which exercise(s) or sport(s)?
e.g. aerobics, fitness, football, baseball, etc.    Please specify

Are there any exercises you like or dislike?
* Love / Hate

Do you have any Home Gym Equipment?
No Yes    Please select

If yes - please describe:
Please list / describe your home gym equipment    Yes, I have

What are your personal fitness goals?
   Reduce body fat
   Improve Cardiovascular (heart / lung) efficiency
   Gain muscle mass / definition
   Improve fitness level
   Tone-up all muscle groups
   Reduce stress levels
   Win championships ^{please go here}

Which body areas do you want to target?
* Concentrate on

Your training goal(s) not covered?
For athletes: event, achievements so far, etc.    Tell me your goal(s)

If you are not currently exercising, please check the days on which you plan to exercise.
   Monday
   Tuesday
   Wednesday
   Thursday
   Friday
   Saturday
   Sunday

How much time will you invest in your program?
* Minutes per day         * Hours per week

Have you ever had, or do you currently suffer from, any of the following ailments?
   Arthritis or rheumatism?
   Asthma, emphysema or bronchitis?
   Stiffness or pain in your Neck?
   Backache or Scoliosis?
   Pain in your knees?
   Sore feet?
   Hernia?
   Diabetes?
   Heart disease?
   Any other chronic illnesses?
   High blood pressure?
   Raised cholesterol levels?
   Any other health problems?
If you checked any boxes, ^{please go here}

Are you currently using any prescribed medication?
Yes No * Medication - If yes, ^{please go here}

Are you pregnant?
Yes No * Pregnancy - If yes - congratulations! ^{Please go here}

Do you smoke or use tobacco?
Yes No * Smoker - If yes, ^{please go here}

If you answered yes to any of the health questions above, tell me about it:    Tell me about it

* Morning
* Midday
* Evening
* Snacks
* Like / Dislike
   Need to tell me more?

* Please check to confirm your agreement with my

Online Consent and Disclaimer Conditions
and my Privacy Policy

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