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First Name
Last Name

Home Address

City

State

Zip

Home Phone				Day Phone
Fax				Email

How did you hear about Rx-Fit?

You are interested in which center?

Calabasas  Encino Club  Beverly Hills

Select the schedule for training appointments that is best for you:

Mon Tues Wed Thurs Fri Sat Sun AM PM

Best time for a first workout?

Best time for a fitness test?

Number of days per week with a trainer:

1    2    3    4    5    6    7

You are interested in which of our services?

One on One    Team Training    Open Member

Exercise History

	Presently?		If yes, what?
	Past?		If yes, why did you quit?
	Injury during activity?		If yes, explain
	Worked with trainer?		If yes, how long?

Nutrition

	Presently Dieting?		comments:
	Breakfast?		comments:
	AM snack?		comments:
	Lunch?		comments:
	PM snack?		comments:
	Dinner?		comments:

Water intake oz:
Alcohol serv/wk:
Caffeine serv/day:

Energy, Sleep, Stress

Energy Highs?		yes no		Time?
Energy Lows?		yes no		Time?
Sleep (at least) 8 hrs?		yes no
Insomnia?		yes no
Sleep Interuption?		yes no
Stress Level?		High  Medium  Low

Fitness Goals

Weight Loss Weight Gain Body Fat Loss Inches Cardiovascular		Strength Flexibility Nutrition Other

Medical History

			List Medications
	Heart Disease/family history
	Elevated Cholesterol/family history
	Elevated Blood Pressure
	Respiratory Illness
	Shortness of Breath/Chest Discomfort
	Diabetes
	Other Prescription Medications?
	Diagnosed with Disease
	Pregnant

	Do you smoke?		How  much?

Orthopedic Limitations - check one if yes

Bad Back		not chronic		chronic, not severely limiting		chronic, severely limiting
Bad Knees		not chronic		chronic, not severely limiting		chronic, severely limiting
Weak Ankles		not chronic		chronic, not severely limiting		chronic, severely limiting
Shoulders/ Neck		not chronic		chronic, not severely limiting		chronic, severely limiting
Hips		not chronic		chronic, not severely limiting		chronic, severely limiting

Please list any past orthopedic problems:

Please use the box below to ask the Rx-Fit Staff anything you wish to know or any comments you wish to share with us: