To help us serve you better for your initial consultation, please download our Questionnaire (pdf). Fill it out the to the best of your knowledge and fax it back to Body Pump Inc. at 416.926.7249.

If you do not have Acrobat Reader, please press here to go to the Adobe Website where it is free to download.

Or just fill out the form below and click on Submit.
Name:

E-mail
Date:
Address:
Address 2:
Phone (Home):
 Phone (Business):

Age:

Birth Date:
Occupation:
Physician's Name:
Physician's Phone: 

Are you presently involved in a regular exercise program? If yes please list activity, duration,
frequency and intensity:

How active do you consider yourself?

sedentary      light   moderate    high 

Do you have a history of high blood pressure (above 140/90)?

Yes No

Have you recently had surgery or experienced bone, muscle, tendon or ligament problems
(specially in your knees or back)?

Yes No  If yes, where:
How would you describe your nutrition habits?
good fair moderate
How many meals do you usually eat each day?
How would you characterize your life?

highly stressful moderately stressful low in stress

Are there any other information you would like us to know concerning your health?

   

 
 
 
 

 


 
 
 

© 2005 Body Pump Inc. All rights reserved.