First Name

Last Name

Date of birth *

Phone *

Email *

Has your doctor ever said you have a heart condition? *

Yes

No

Do you feel pain in your chest during physical activity? *

Yes

No

Have you had chest pain when NOT doing physical activity in the past month? *

Yes

No

Do you lose balance due to dizziness or lose consciousness? *

Yes

No

Do you have a bone or joint problem that could worsen with activity? *

Yes

No

Are you currently taking medication for blood pressure or a heart condition? *

Yes

No

Do you know of any other reason you should not engage in physical activity? *

Yes

No

Current Pain Level *

Are you currently under doctor or physical therapist care? *

Yes

No

What equipment do you have access to? (Select all that apply) *

Dumbbells (10-50+ lbs or adjustable set)

Adjustable bench or stable elevated surface

Weight machines (leg press, chest press, lat pulldown, etc.)

Cable machine

Resistance bands (long bands with or without handles)

Mini resistance bands (small loop bands)

What best describes your training experience? *

How comfortable are you with strength training movements? *

How many days per week do you want to train? *

What's your primary goal with this program? (Optional)