BodySTARR LLC Group Fitness Program Form

BodySTARR LLC Fitness Program

Registration Form must be completed before beginning any type of Fitness Program.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home Number*

Area CodePhone Number
Cellular Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Birthdate*

MonthDayYear
Height
Weight
Occupation
Health Status*

ExcellentGoodFairPoor
When was your last physical exam (Should be within the last year)*
What is your Blood Pressure?
Are you Presently on medication for Blood Pressure, if so what is it?
Do you have any health conditions?*

YesNo
If answered Yes, please describe.
Do you take any dietary supplement?

YesNo
If answered Yes, what type?
Do you Presently Smoke?

YesNo
If answered Yes, do you plan to quit?
Should be Empty:

BodySTARR LLC Fitness Program