Personal Profile Form:

Tell me about yourself. The information that you provide will be kept in the strictest confidence. Please be specific. I will respond to you as quickly as possible.

Name*
E-mail address
Phone number*	- - (area code)
Gender
Age
Height	feet          inches
Weight
What are you most interested in achieving with your fitness program?	Lose fat and improve muscle tone Muscle sculpting, strengthening and toning Lose fat AND do muscle sculpting, strengthening and toning Improve performance for a specific sport, activity or event Decrease pain/rehabilitate an injury
Do you have any injuries?	Yes No
If so, please list
Do you take any medications for high blood pressure, diabetes, cholesterol or heart?	Yes No
If so, please list
Do you suffer from any joint problems?	Yes No
If so, please list
Have you been inactive over past 12 month?	Yes No
From 1-10, how do you rate your over-all health?
What goals would you like to accomplish?
Note to Trainer Nicki. What else would you like her to know about you?
What are the most convenient times for you to meet with your trainer? ( You may select several)	Monday Tuesday Wednesday Thursday Friday Saturday 7-30AM - 11-30AM 12-30PM - 5-30PM 6-30PM - 8-30PM
How many times a week would you like to meet your trainer?
Enter the Verification Text to the Right:	If you can't read the word above, click here
* required fields

Contact Trainer Nicki - NickiGeigert@aol.com