Date: May 24th, 2013
Name:
Address:
City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Email:
Home Phone: ( ) -
Work Phone: ( ) -
Date of Birth: Month: January February March April May June July August September October November December Day: Year:
Occupation:
Height:
How Will You Be Paying?
Credit Card Card Type: Visa MC AMEX Discover Card Number: Expiration: Month January February March April May June July August September October November December Day: Year:
Money Order Mail your money order to Dellis Health & Performance, 3130 W Lambright #115, Tampa, FL 33614 Date Mailed:
Would you like one payment or two? One payment of $399.00 Two payments of $199.50
List any present or past illnesses, injuries or conditions and when they initially occurred:
List any medications (prescribed and/or over the counter) you are currently taking and when you first started taking them:
Do you exercise regularly? Yes No
If yes, where do you exercise?
What types of exercise and what is the duration and frequency of your exercise sessions?
What types of exercise equipment do you have at home?
What times can you exercise throughout the week? Mornings Afternoons Evenings
How may meals do you have each day? Do you eat breakfast? Yes No How many tobacco products do you use per week? At what age did you start smoking? How many alcoholic drinks per week? What type of alcohol? How many caffeinated beverages do you drink per day? How many non-diet sodas do you drink per day? How many glass of water do you drink per day?
List any food allergies:
Do you have an eating disorder? Yes No Are you a vegetarian? Yes No If yes, do you consume dairy products? Yes No Are you aware of the number of calories you consume daily? Yes No If yes, how many? Have you ever weighed your food? Yes No Do you read food labels? Yes No Do you eat out often? Yes No If yes, what type of restaurant and how often?
The impact of stress on our overall health and well being can't be underestimated. Every day, we face both physical and psychological stress. Some kinds of stress are out of our control; others may be triggers we aren't consciously aware of. Regardless of the source of stress, it must be managed to achieve maximum health and fitness.
The first step is look for and acknowledge the stress triggers in our lives.
Please answer these questions, using a scale from 1 to 5, where 1 is "rarely" and 5 is "frequently".
When do you wake up? When do you arrive at work? When do you eat lunch? When do you leave work? When do you go to bed? When is your morning workout? When is your morning scheduled break (a.m.) ? When is your afternoon scheduled break (p.m.) ? When is your Evening workout?
What are your hobbies or recreational activities:
What are your specific goals? Lose body fat? Build Muscle Mass? Tone & Define? Improve coordination or sports related skills? Other:
Do you have a refrigerator at work? Yes No
Do you have a microwave oven at work? Yes No
Please fill out only Present Body Weight and Body Fat. You will be contacted by a Dellis Health & Performance representative for goal setting.
PRESENTLYBody Weight: Body Fat%:
GOALBody Weight: Body Fat%: