Information & Health History

Please complete the "Info & Health History" form entirely.   Be sure to click in the "I'm not a robot" Captcha box before you hit the submit button. Your form will be sent my inbox and a copy will be emailed directly to you. I recommend that you print out or save a copy of the form for your records and future review.

Once you are accepted into the program you will receive an email from me instructing you what to do next as you prepare to begin the program.

  • MM slash DD slash YYYY
  • A copy of this form will be sent to this email address.
  • EMERGENCY CONTACT:

  • HEALTH HISTORY:

  • PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING:

  • LONG TERM GOALS AND OBJECTIVES FOR YOU AND YOUR BODY:

  • Specific Body Areas: (ie; arms, legs, abs, glutes, etc.)