Up 2 Speed Training > Forms > Registration Questionnaire

First Name:

Last Name:

Email Address:

Date of Birth:

Please enter a value for the field Weight.

Weight (Pounds):

Gender:

Please enter a value for the field To lose.

To lose weight?:

If Yes Then How Much?:

Lose inches?:

Tone up and/or enhance muscle definition?:

Improve your strength?:

Maintain current weight?:

Increase stamina and cardiovascular performance:

Please enter a value for the field How many hours per week are you.

How many hours per week are you realistically able to devote to exercising?:

Other Goals?:

Please enter a value for the field Medical History.

Medical History: (Please select ALL that apply):

Been seen by physician in the last 12 months
Cleared by a physician to exercise
Current Pregnant
Given birth in the past 6 weeks
Diagnosed with heart disease
Had a heart attack
Had a stroke
Have high blood pressure

Please enter a value for the field Chest ().

Chest (Take a lose measurement at nipple level, running tape from behind you to the front):

Please enter a value for the field Rib cage.

Rib cage (Wrap tape measure around the ribs, just undermeath breast area.):

Please enter a value for the field Waist .

Waist (Run the tape across navel from behind you to the front.):

Please enter a value for the field Abdomen.

Abdomen (Measure circumference three inches below navel.):

Please enter a value for the field Hips.

Hips (Stand with legs together and run tape across largest part of butt.):

Please enter a value for the field Upper thigh.

Upper thigh (Measure your upper right thigh just below the buttock fold.):

Please enter a value for the field Calf.

Calf (Measure your right lower leg around the largest part of the calf.):

Time:

Please enter a value for the field Heart rate.

Heart Rate For 60 Seconds: