Registration

My Fieldset

Name*
Email*
Phone*
Date of Birth*
How did you find out about the Power Hour?*
What is the single most important thing we must accomplish together?*
How would you rate your current level of fitness? Poor, Fair, Average, Good, or Excellent?
Poor Fair Average Good Excellent
List your favorite sports/fitness activities … anything that is physical and you enjoy.*
Is there anything that has been holding you back from reaching your goals? If so, please describe.*
Briefly describe your specific, short-term goals (within the next 12 weeks) with regard to your body, health and fitness.*
Now describe your specific, long-term goals (beyond 12 weeks) with regard to your body, health and fitness.*
Have you been diagnosed with any health conditions and / or are you currently taking any medications that I should be aware of? If so, please list and explain.*
Are you currently exercising? If so, how many times per week and what type? Please list how much or how long. For instance, walking for 20 minutes, four times per week.*
If you answered no, when was the last time you participated in regular exercise consistently? If never, just say never -- we’ll get you there.*