Dellis Health & Performance

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I wake up at:

Morning workout:

I arrive at work at:

Scheduled break (a.m.):

I eat lunch at:

Scheduled break (p.m.):

I leave work at:

Evening workout:

I go to bed at:

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Dellis Health & Performance	Nutrition & Exercise Training Products & Services
(800) 318-8369 ~ E-mail orders@dellis.com "Teaching Nutrition & Exercise for a Healthy Lifestyle"

Client Profile

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PLEASE NOTE: You must have a health club membership to be able to carry out this program. If you do not have a health club membership, please do not fill this form out.

Date:
Name:
Address:
City:	State: Zip:
E-mail:
Home Phone:
Work Phone:
Date of Birth:	Age:
Occupation:
Height:	Current Weight:

Payment

How will you be paying?

Credit Card

Card Type:	VISA MC AMEX Discover
Card Number:	Expir. Date:

Money Order
Mail your money order to Dellis Health & Performance, 3130 W. Lambright #115, Tampa FL 33614
Date Mailed:

Medical Information

Do you consider your health to be: Excellent Good Fair Poor

List any present or past illnesses, injuries or conditions and when they initially occurred:

List any medications (prescribed and/or over the counter) you are currently taking and when you first started taking them:

Exercise Habits

Do you exercise regularly? Yes No

If yes, where do you exercise?

Please explain in detail what type of exercise program you are currently on, if applicable.

What is the duration and frequency of your exercise sessions?

What types of exercise equipment do you have at home?

What times can you exercise throughout the week?
Mornings Afternoons Evenings

Schedule

General Information

What are your hobbies or recreational activities:

What are your specific goals?

Lose body fat Build muscle mass Tone & Define

Improve coordination or sports related skills

Improve cardiovascular endurance

Other:

Additional Comments