Online Application for online training

Online Get Fit in 6 Application

Thank you for your time to apply to this fantastic opportunity!
Please complete all ten questions and the health survey.

Name:

Email address:
Please use the email that I will be sending your series to with your paypal or notify me via email if it is different.

Have you ever done a fitness program before and did it work, why or why not?

Have you been on Diets before (which ones)?

Have they worked (why or why not)?

Why do you think this program would be good for you?

How determined are you to get to the goal that you want?

What do you expect to accomplish in my 6 week Online Get Fit in 6 program?

What do you feel are your biggest obstacles that have stopped you from attaining your goals in the past?

Do you consider yourself an open person and a listener?

Are you able to follow instructions and have access to a computer regularly?

Are you ready, determined, and motivated to change your life for the better (be as descriptive as possible in a paragraph or two….this is a very important question. Depending on your answer will allow me to make a clear decision)???

Part 2 Online Health Questionnaire Get Fit in 6 Application Part 2
Please complete all questions to the best of your ability. Each requires an answer.
Name:	Age
Street Address	Date of Birth
Email Address	Cell Phone Home Phone
Weight	Height
Physician's Name	Physician's Phone
Symptoms
Has a doctor ever said you have, or are being treated for: heart trouble, heart palpitations, coronary disease, or high blood pressure? if Yes, describe
Do you have chest pains? if Yes, describe how often, doctor's advise
Shortness of breath at rest or at mild exertion?
Do you suffer from dizziness or fainting?
Do you experience any pain in your limbs when exercising or moving?
Risk Factors	List any not mentioned below
Smoke?
Suffer from Diabetes?
Anyone in your family suffer from coronary disease prior to age 55?
Pregnant or think you may be?
Medications/ Limitations/ Medical History:
Are you on any Medications currently?
For what conditions?
Allergies? If yes what are they? Medications for these allergies?
Do you have any physical limitations that would limit your ability to exercise?
Surgeries?
Physical Activities/Self Image
Do you practice stress management? What methods?
Do you partake in regular physical activity? Duration? How many times a week?
What are your primary goals?
Goals for: Weight loss? Increase Lean muscle mass? Increase Performance? Decrease Pain? Tone?	List each
Read the paragraph below and check agree to submit your full and completed application and this health survey. By checking below the paragraph you are submitting to getfitin6.com your Electronic Signature as well as your acceptance of the statement.
I pledge that all the information which I have provided in this form is accurate, to the best of my knowledge, and that I have not willingly excluded any important medical information which could have any bearing on my ability to safely engage in exercise testing and exercise participation. I further agree to notify Yarixa Ferrao should my health status change during the future of the course. Check box commits to I Accept and your electronic Signature!
Before you click submit, All fields require an answer; even if it's a No, N/A or a None.