PERSONALIZED WORKOUT PROGRAM

by David Silva

General Instructions: Please fill out the form below as completely as possible. Fields marked with * must be correctly completed in order to get your fitness program done
Is it your first time ordering a workout program here * Yes No
If not, please your workout code #
Last name *
First name *
Address *
City *
State *
Zip code *
Country *
Telephone : Home *
Work
Portable
E-mail *
Gender * Male Female
DOB *
Weight * lb kg Body fat %
Height *

Inches Cm

Smoker *

Yes No, If yes, How many daily

Please rate yourself - For the following questions please use scale 1 to 5.

characterize your present cardiovascular capacity
characterize your present muscular capacity
characterize your present flexibility capacity

2.What do you want exercise to do to you:

improve cardiovascular fitness
body-fat weight loss
muscular mass gain
reshape or tone my body
improve performance for an specific sport
improve moods an ability to cope with stress
improve flexibility
increase strength
increase energy level
feel better
enjoyment
other

3. How much are you willing to devote to an exercise program?
Resistance (weight lifting):
minutes/day
 days/ week
Endurance (cardiovascular) :
minutes/day
 days/ week

4. Are you involved in regular endurance exercise? If yes, please specify
A minutes/days days/week
A minutes/days days/week

5. What types of exercise interest you? (Yes or NO)
walking Yes No
jogging Yes No
swimming Yes No
cycling Yes No
strength training Yes No
stationary biker Yes No
tennis Yes No
stretching Yes No
other

6. Do you belong to a Fitness Center or Gym?

Yes No , if yes
name
location

7. Would you like your Fitness Program to include gym equipment? (No, if you just want exercise that not require equipment)
Yes No

8. Is there any part of your body you would like to concentrate on for any reason:

Yes No

 if yes, which part ?

9. Would you like to change your current weight ?
Yes No
If yes, by how much?
gain lb kg
loose lb kg

10. Have you ever had any kind of health problem such as respiratory, spinal, heart, bone fracture, etc. or have you ever been advised by a doctor or any other physician to not participate on any kind of sport or exercise? If so, please explaining
 
 

11. If you have any other comment (background, health problem, goals, etc.) to make, in order to clarify any above question(s) or to help building the most appropriate fitness program, please do so:
 
 
 
Disclaimer:Before beginning any exercise program always consult your doctor to make sure you are able to begin exercising. Certain disabilities or conditions may contraindicate some activities, so be sure to clear yourself with your doctor.“I understand that is my responsibility in case of any injury incurred because of following this fitness program and all the above answers are real and accurate, releasing David Silva from any kind of liability
I agree
 
How did you find about us?
 
 
 
Workout Program US$ 110.00
 
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