Welcome to the first step in the Fitness Evolution Program. Once we get down the basics, we can start the training.

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Part One: Background Information
Name:
E-Mail Address:
Phone:
Sex:	Female Male
Age:
Height:
Weight:
Current Body Fat (If Known):
Intermediate Goals:
Long Term Goals:
Occupation:
Part Two Health History
Have you ever required medical attention or had symptoms pertaining to any of the following? If you check yes to any of these categories, please provide details below.

Cardiovascular System:	coronary artery disease, valvular dysfunction, myocardial infarct, murmur, rheumatic fever, palpitations, hypertension, chest pain, shortness of breath, etc.?	No Yes
Central Nervous System:	dizziness, headache, seizure, fainting, stroke, paralysis, polio, MS, cerebral palsy, etc.?	No Yes
Circulatory System:	peripheral vascular disease, varicose veins, phlebitis, blood clots, stroke, blood disorders, anemia, enlarged lymph nodes, etc.?	No Yes
Digestive System:	mouth, tongue, or esophageal disorders, gastritis, ulcers, pancreatitis, gall stones, liver disease, cirrhosis, hepatitis, chronic diarrhea, hemorrhoids, hernia, colon, intestinal, or rectal disorders, etc.?	No Yes
Endocrine System:	diabetes, gout, thyroid or adrenal disorders, hormone deficiencies, etc.?	No Yes
Genito-Urinary System:	kidney stones, urethra, bladder or kidney disorders infections, strictures, etc.?	No Yes
Female Reproductive:	abnormal bleeding, amenorrhea, endometriosis, fibroids, breast problems, infections, etc. Are you currently pregnant, lactating, or planning to get pregnant	No Yes
Male Reproductive:	prostate, infertility, gynecomastia, infections, etc.?	No Yes
Immune System:	lupus, Raynauds, HIV, ARC, AIDS, etc.?	No Yes
Musculoskeletal System:	fractures, dislocations, sprains, sciatica, herniated discs, scoliosis, muscle bone or joint injuries, arthritis, rheumatoid arthritis, carpal tunnel syndrome, amputations, etc.?	No Yes
Psychiatric:	depression, bipolar disorder, anxiety, panic attacks, schizophrenia, anorexia, bulemia, substance abuse, etc.?	No Yes
Respiratory System:	asthma, allergies, bronchitis, sinusitis, emphysema, tuberculosis, pneumonia, COPD, etc.?	No Yes
Surgical History:	Please list the date and type of any cosmetic, orthopaedic, reconstructive, bypass, transplant, or other surgery you have undergone.
Please list all medications you are currently taking, both prescription and OTC:
Please provide details for any of the above and indicate other medical conditions or illnesses not mentioned above
Part Three: Exercise
Estimate your activity level: Check the category that most accurately describes your current activity level. Include only cardiovascular or weight training activities:
Sedentary to 20 minutes twice a week 20-30 minutes two to three times per week 30-45 minutes three to four times per week 30-45 minutes to one and a half hours three to four times per week 30-46 One to one and a half hours five to seven times per week Two hours or more three to four times per week Two hours or more five to seven times per week
Part Four: Eating Habits
Approximately how many times per day do you have a "sit-down" meal?
How often do you snack
Describe what you eat in a typical day:
Do you have any dietary restrictions?
Do you ever experience cravings?
For what kind of food?
What time do you usually get up in the morning?
When do you first eat during the day?
What time of day are you hungriest?
Do you use dietary supplements?
If yes, which ones?
Have you ever used other nutritional systems or diet programs? If yes, which ones? How successful were you at achieving your goals?

Thanks, now all you have to do is click on the "Send" button below. Or, if you would like to start over, click on the "Start Over" buttom to erase all your answers and begin again. Thank You.