Healthy Targets 9-Week Fitness Challenge Enrollment - Contact Information
For you to get the most from your coaching experience complete the form below to the best of your ability. Upon completion, Submit this page. Complete your Enrollment at the next page after submission and you will contacted within the next 48-hours. I am looking forward to helping you achieve your Personal Best!

Fight for YOUR Life!
David Berger


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Did someone refer you? If so, enter their name here:
How did you hear about Number One Me?

Step Two -- General Information

In order to create a customized training program that is designed just for YOU, we need some general information about you, your health and your current exercise level.  This information is confidential -- please answer each question to your best knowledge so that we can provide you with the very best program to help you reach your goals.  For example, if you currently lead a sedentary lifestyle, that's okay but please be sure to indicate that in the Current Exercise Regimen section below.

Statistics:

Date of Birth:     Month    Day    Year      

Weight: pounds

Height: Feet  Inches        

Gender: 

 

What Are Your Personal Goals? 

To lose weight ?      If Yes ThenHow Much?    

Lose inches ?          

Tone up and enhance muscle definition?

Gain more strength?      

Maintain current weight and muscle tone?

Increase stamina and cardiovascular performance?

How many hours per week are you realistically willing to devote to exercising?

Other Goals?

If fitness goals are for a specific event (e.g. Wedding), provide the event's date, etc.:

Note: If you have other information that you think is important for your coach to know when designing your personalized program, you will have the opportunity to provide more details via e-mail. You will be provided an e-mail address in your enrollment welcome communication.

Medical History: (please select ALL that apply)

Been seen by a physician in the past 12 months

Currently pregnant

Diagnosed with heart disease

Had a stroke

Have arthritis

Have diabetes

Previous allergic reaction to exercise

Currently taking medication for chronic condition

         What is the medication for?      

        

Recent fracture, sprain or dislocation

Other conditions we should know about (please specify):

Cleared by a physician to exercise

Given birth in the past 6 months

Had a heart attack

Have high blood pressure

Have asthma

Experienced seizures

Previous chest pain or numbness

Currently have a cold or influenza

Recently had surgery

 

 

Current Exercise Regimen  -- please select ANY exercises that you currently participate in. Or, if you currently aren't doing any exercise but have worked out consistently in the past 3-4 months, indicate what you were doing.

  Mark which information you are providing:   

Current routine Past routine (within 3-4 months) 

 

  Cardiovascular Training    
  Type (Check applicable) Frequency Session Length Average Pace
 
Walk
  MPH
  Jog   MPH
  Swim  Not applicable
  Step or Hi/Lo Aerobics  Not applicable
  Kickbox  Not applicable
  Other (please specify)    
         
  Strength Training Frequency Average Weight Size  
  Dumbbells  
  Weight Machines  
         
  Mind/Body Frequency Session Length  
  Yoga  
 
Pilates
 

Fitness Equipment: (select ALL equipment that you either own or have access to):

Treadmill Dumbbells
Resistance Band Step for Step Aerobics
Exercise Stability Ball (highly recommended!) Jump Rope
Elliptical Bike
Bosu Weighted Bar
Home gym Barbell

Access to fitness club    

     Does it offer aerobics classes?

Other equipment   

     (please specify)

 

Release of Liability

Do you agree to the release of liability terms detailed above?

  By choosing Yes you are indicating that you have read the Release of Liability above, fully understand and accept its terms and that you have given up substantial rights by accepting these terms.

Membership Agreement and Terms of Use

Do you agree to the membership agreement and terms of use detailed above?

By choosing Yes you are indicating that you have read the Membership Agreement and Terms of Use above and fully understand and accept its terms.

Please note: it may take a few seconds to process, so you only need to hit submit once. If it takes longer than 60 seconds or you receive an error, try hitting submit again or contact us