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| Personal Information | ||||
| Last Name |
First Name |
Middle Initial |
Age |
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| Mailing Address |
City |
State
Zip Code |
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| Gender |
Email Address |
Height |
Weight |
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| Preferred Physical Activities (Check All That Apply): | |
| 1. | Walking Swimming Running Cycling Aerobics Weights Other |
| 2. | Do you have a set time that you exercise? Yes No |
| 3. | Do you have an exercise routine you like? Yes No |
| 4. | How many days a week do you exercise? |
| 5. | How many minutes-average per exercise period? |
| 6. | Where do you exercise? Office Gym Home Other |
| 7. | Do you monitor your heart rate? Yes No |
| 8. | Do you make healthy selections from the five food groups? Yes No |
| 9. | Do you keep a daily log of the food you consume? Yes No |
| 10.. | Do You Know you Body Mass Index (BMI)? Yes No |
| 11. | Have you figured your - Target Heart Rate? Yes No |
| 12. | Have
you been on a weight control program in the past? Ten Years Yes No Five Years Yes No One Year Yes No |
| 13. | Have
you had a physical checkup with a doctor in the past? Ten Years Yes No Five Years Yes No One Year Yes No |
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SLIM n' TRIM, INC., Pasadena, CA 91105-3350