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  World's Best Trainer Offline Shopping Form
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Worlds Best Trainer
1 Tuxedo Drive
Melville, NY 11747

Please Make Check or Money Order Payable to George Baselice

     
Check

Product Name

Price

...Total...

George's Diet $20.00 $

George's Workout $20.00 $

Carmela's Diet $20.00 $

Carmela's Workout $20.00 $

Bowflexercise & The Turning

Point Book

$24.95

+$5.00 S&H

$
  Check/Money Order Only Total $
     
     
Name
Address
 
E-mail Address

If Ordering Customized Workout, PleaseFill in as much as possible.

Name:
Address:
E-mail Address:
Home Phone:
 
   
Physician's Name: Phone:
Date of last physical examination: Resting Heart Rate:
 
   
Height: Weight: Bodyfat:
Age: Birthdate: Blood Pressure:
Measurements: Shoulders: Thigh:
Calf: Waist: Hips:
 
   
What are your fitness goals?
Weight (fat) loss Gain Weight (muscle mass) Improve eating habits/overall health
 
   
Have you ever been in a structured weight loss program ?
NO
YES (explain)
   
Health History:
 

YES

NO

UNSURE

Do you smoke?

Has your doctor ever said you blood pressure was too high/low?

Has your cholesterol level was to high?

Do you have any injuries or orthopaedic problems(bad back)?

Have you ever taken any prescribed medications or dietary supplements?

Are you currently involved in a regular exercise program?

 
   
Have you ever had or currently have any of the following conditions. Check any that apply?
  YES   YES   YES   YES
Heart Disease

Hypertension

Hypotension

Diabetes

Liver Disease

Bulimia

Headaches

Asthma

Anemia

Hypoglycemia

Angina

Croh's

Flatulence

Pancreatic Disease

Bloating after meals

Anorexia

     
   
General Health & Nutrition
What type of supplements and how are they delivered?
Do you have any other medical conditions? Explain.
 
   
Rate your health. Excellent Good Fair
Rate your activity lavel at work. Sendentary(desk job) Active Extremely Active
     
   
How often do you currently exercise? Week
How long is each session? Hours
Total hours a week? Hours
           
   
Do you have any other medical condition or problem not previously mentioned?
What are your goals with this program?
Additional comments:

 
 
   
What have you eaten in the last three days.
Day 1 Day 2

Day3

    Consent Form:   Signature:   Date:          
    *I acknowledge, to the best of my ability, that I am in good health and have no known medical problems that would restrict my ability to participate in this exercise program. I am committed to making a positive change in my health through my participation in the program. I understand that certain aspects of this program can be physically demanding. I also understand that I will need to change various aspects of my life in order to obtain the goals I have set forth. As a condition of my enrollment, I accept full and complete responsibility for my own ability to healthful participation in this program. This means I acknowledge that I should obtain a physicians approval of my participation in this program. I agree to hold George Baselice/Carmela Baselice and the facility of World's Best Trainer/worldsbesttrainer.com employees, shareholders, successors and assigns free from any and all liability in connection with my performance or medical conditions that might arise. I willingly and knowingly assume for myself and my heirs executors, administrators and assigns any risk which is associated with my participation in this or any program related to World's Best Trainer/worldsbesttrainer.com  
    Signature______________________Date:________________

 

 
 

 
 
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