Your Quick Start® report can be customized for you based on the responses to the following questionnaire.

The following questions probe quite deeply into your current and past exercise, diet, and lifestyle habits.
They will serve as a basis for me to help you establish a regimen that will assure you continue to balance
your lifestyle to your full potential, a day at a time, for the rest of your life.

All information is voluntary and will be kept confidential.

Name_________________________________________________________________

Address_______________________________________________________________

City_________________________________State_____________Zip______________

Credit Card Visa MC

Number__________________________ Expiration Date_______________

Day Phone_________________________Evening Phone________________________

Date of Birth__________________Sex________Race________Marital Status________

Email Address__________________________________________________________

Profession_____________________________________________________________

Today's Date__________________

Your Weight__________Your Height_____________Your Desired Weight____________

What can you tell me about your medical history?

BODY COMPOSITION ASSESSMENT (omit any answers you don't know, but read
through all the questions--you'll have the option of filling in the blanks
during the class.)

If yes, what was your % body fat?_____________

Please take the following four measurements. There is now sufficient
research to be able to do a body composition assessment using a tape
measure.

FOR WOMEN

1. Abdomen: Standing tall, with heels together, exhale then measure one
inch above the umbilicus (belly button).

My abdominal measurement in inches_________________________

2. Right thigh: Standing with feet shoulder width apart and legs straight,
measure the upper thigh just below the buttocks.

My right thigh measurement_________________________

3. Right forearm: measure arm in the widest place when the arm is extended
in front of the body, palm up.

My right forearm measurement_________________________

4. Right calf: measure at the widest part midway between the ankle and the knee

My calf measurement_________________________

FOR MEN

1. Right upper arm: Holding the arm straight, palm up and extended in
front of the body, measure at the midpoint between the shoulder and elbow.

My right upper arm measurement_________________________

2. Abdomen: Standing tall, with heels together, exhale then measure one
inch above the umbilicus (belly button).

My abdominal measurement in inches_________________________

3. Right forearm: measure arm in the widest place when the arm is extended
in front of the body, palm up.

My right forearm measurement_________________________

4. Buttocks. Standing tall, with your heels together, measure at the widest part.

My buttock measurement in inches_________________________

Check the appropriate description of your weight during the last year.

Exercise