* NOTE: All information in yellow boxes is required * How did you hear about us? Personal Information * Name:  * Home # * Address: Office #   Cell # * City:      * State:    *Zip Code:      * email address:     * D.O.B.     Height:        * Weight (current)      * Weight (1 yr. Ago) Health Information * Have you exercised within the past 6 months?     Yes   No Type of exercise and duration: Are you dieting? YES NO Type of diet: Eating habits: Do you smoke? Yes No          If yes, how many cigarettes or packs per week? Do you drink?    Yes No          If yes, how many alcoholic beverages per week?   HEALTH HISTORY Indicate any diseases or illnesses you have had or currently have: Heart attack Cardiac catheterization Abnormal stress test Heart trouble High blood pressure Low blood pressure Coronary bypass surgery Stroke Diabetes Chest pain or angina Convulsions Loss of consciousness Angioplasty Asthma MS High Cholesterol Limitations of movement Knee problems/surgeries Difficulty breathing Back problems/surgeries Shoulder problems/surgeries Irregular heart beat/rhythm thought to be significant by a physician If you answered yes to any of the above questions, please explain in further detail:        Date