Register
Please note it will take about 5 minutes to fill out the whole form.
All fields are mandatory.

Username
Invalid Input
Email
Invalid Input
Password
Invalid Input
Package
Invalid Input



All fields are mandatory.

Use only the form's back and next buttons, instead of the browser back button.



"To register please fill in the information below for each section."
Today’s Date
Invalid Input
Name
Invalid Input
Birth Date Age       
Invalid InputInvalid Input
Home Address
Invalid Input
Zip
Invalid Input
Home Phone
Invalid Input


*If not currently employed please click "Not applicable".
Employer
Invalid Input
Occupation
Invalid Input
Business Address
Invalid Input
Business Phone
Invalid Input
Not applicable


Emergency Contact
Invalid Input
Relationship
Invalid Input
Address
Invalid Input
Phone
Invalid Input


Physician
Invalid Input
Address
Invalid Input
Phone
Invalid Input
Date of last physical
Invalid Input
Current Medications
Invalid Input
May I have permission to contact your physician regarding your health status?   
Invalid Input



Family Medical History: List any of your parents or siblings who had the following diseases and their age at the time of occurrence.
*If your answer to each text field below is "none" please click "Not applicable".
Relative Age
Cancer
Invalid Input
Invalid Input
Cardiovascular disease, including
Heart attack
Invalid Input
Invalid Input
High blood pressure
Invalid Input
Invalid Input
High cholesterol
Invalid Input
Invalid Input
Stroke
Invalid Input
Invalid Input
Diabetes
Invalid Input
Invalid Input
Obesity
Invalid Input
Invalid Input
Osteoporosis
Invalid Input
Invalid Input
Not applicable



All fields are mandatory.

Use only the form's back and next buttons, instead of the browser back button.





Personal Medical History: Check the conditions you currently have. If a condition occurred in the past, please check it and indicate how long ago.
*If your answer to each below is "none" please click "Not applicable".
Invalid Input
Other
Invalid Input
Any recent illness, hospitalization or surgery?
Invalid Input
Not applicable



History of Osteoporosis:
*If your answer below is "none" please click "Not applicable".
When was your last bone density test?
Invalid Input
What areas – spine, hip, wrist – show osteopenia or osteoporosis?
Please enter your T-score below:
Spine
Invalid Input
Hip
Invalid Input
Wrist
Invalid Input
Not applicable



History of Breast Surgery:
*If your answer is "none" please check “Not applicable”.
Type of breast surgery
Invalid Input
Date of surgery
Invalid Input
Did you have an axillary node dissection?
Invalid Input
How many nodes were removed?
Invalid Input
Did you have reconstruction?
Invalid Input
What kind?
Invalid Input
Did you have radiation?
Invalid Input
Side effects?
Invalid Input
Did you have chemotherapy?
Invalid Input
Side effects?
Invalid Input
Do you have any unusual pain, numbness or restricted movement?
Invalid Input
Which physician would you like to provide medical clearance for your exercise program?
Name
Invalid Input
Phone
Invalid Input
Address
Invalid Input
Not applicable


All fields are mandatory.

Use only the form's back and next buttons, instead of the browser back button.





Orthopedic History: Describe any bone, joint or muscle injuries that you presently have or have had in the past (i.e neck, shoulder, elbow, low back, hip, knee problems).
*If your answer below is "none" please click "Not applicable".
Do you presently have pain in any part of your body?
Invalid Input
Not applicable



Current Physical Activity History
Do you engage in physical activity on a consistent basis?
Invalid Input
How long have you exercised?
Invalid Input
Describe your routine
Invalid Input


Past Physical Activity History
If not currently exercising, have you in the past?
Invalid Input
When?
Invalid Input
Describe your past routine
Invalid Input
What sports and recreational activities do you enjoy?
Invalid Input



Personal Fitness Goals:
Invalid Input
Other
Invalid Input



Health Related Behaviors: Circle your degree of satisfaction (1-6). Circle YES if you plan to change and NO I if you do not plan to change:
6 = COMPLETELY SATISFIED
5 = Mostly satisfied
4 = Partially satisfied
3 = Partially dissatisfied
2 = Mostly dissatisfied
1 = COMPLETELY DISSATISFIED
Plan to Change
Overall Health
Invalid Input
Invalid Input
Overall Fitness
Invalid Input
Invalid Input
Activity Level
Invalid Input
Invalid Input
Energy Level
Invalid Input
Invalid Input
Weight/Body Fat
Invalid Input
Invalid Input
Eating Habits
Invalid Input
Invalid Input
Blood Pressure
Invalid Input
Invalid Input
Managing Stress
Invalid Input
Invalid Input
Managing Time
Invalid Input
Invalid Input
Sleep Patterns
Invalid Input
Invalid Input
Smoking
Invalid Input
Invalid Input
Alcohol Use
Invalid Input
Invalid Input
Positive Attitude
Invalid Input
Invalid Input
Additional comments
Invalid Input


All fields are mandatory.

Use only the form's back and next buttons, instead of the browser back button.




INFORMED CONSENT: PHYSICAL FITNESS PROGRAM

General Statement of Program Objectives and Procedures: I understand that this physical fitness program may include exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle strength, endurance and flexibility; bone mass), and to improve body composition (decrease of body fat with an increase in weight of muscle and bone). Exercises may include aerobic activities (treadmill walking/running, bicycle riding, stair climbing, rowing machine exercise, etc.), calisthenics and weight lifting to improve muscular strength and endurance, and stretching exercises to improve flexibility.

Description of Potential Risks: I understand that the reaction of the heart, lung and blood vessel system to such exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate, ineffective functioning of the heart, and in rare instances, heart attacks. Use of the weight lifting equipment and engaging in heavy body calisthenics can lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression and safety procedures are not followed.

Description of Potential Benefits: I understand that a program of regular exercise for the heart and lungs, muscles and joints has many associated benefits. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in psychological function and a decrease in risk of heart disease.

I have read the foregoing information and understand it; any questions which have occurred to me have been answered to my satisfaction. Any information obtained during the course of the training sessions will be treated as privileged and confidential and will not be released or revealed to any person other than my physician without my expressed written consent.

Required!


All fields are mandatory.

Use only the form's back and next buttons, instead of the browser back button.




WAIVER AND RELEASE OF ALL CLAIMS BY CLIENT

The CLIENT acknowledges that any program of fitness exercise involves a risk of injury.

The CLIENT represents that he/she has been recently examined by a medical doctor and been found able to undertake a program of exercise.

For and in consideration of the design of an exercise program for CLIENT by Joan Pagano (“TRAINER”), CLIENT agrees:

  1. that any exercise program shall be undertaken by CLIENT at his/her sole risk; and
  2. that TRAINER shall not be liable to CLIENT, nor any other person, for any claims or causes of action whatsoever (including injury or damages resulting from acts of active or passive negligence) arising out of or connected with the services of TRAINER; and
  3. that CLIENT hereby releases and discharges TRAINER from any such claims or actions.
Required


*
Required