General Information Form          
Please complete this form to help me gain a better understanding of who you are and your personal fitness goals.
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First Name *
Last Name *
Street Address *
City *
State *
Zip Code *
Email Address *
Cell Number *
Name & Number For Emergency Contact *
May We Text You *
Date of Birth *
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Current Weight *
Height *
Gender *
Fitness/Activity Level *
Do you have any recent Injuries or Chronic health conditions, High Blood Pressure, Heart Issues, Breathing Problems, Chest Pains, etc. Past or Present. *
Please explain in detail
Are you taking any medications, supplements, or over the counter aids? *
Please list names, does, and reason.
When Was Your Last Physical Exam *
Do You Need and or Have You Had Medical Clearance To Begin A Physical Fitness Program? *
How often do you eat fast food, sweets, sugar and or sugary foods, or Junk Food Snack? *
Do you drink Alcohol? *
What are your health and wellness goals? *
Describe any things that contribute to any stress you may have or experience. *
What type of Physical Activities do you like to do? Check all that apply. *
Required
Would you like to Sign Up For Kevin Dwayne's October Fitness Challenge *
How did you hear about Kevin.Dwayne's Mind & Fitness Inc? *
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