document.write("Personalized Fitness Program Request Form\n"); document.write("\n"); document.write("\n"); document.write("function TAMax( ta, countspan, maxlength ) {\n"); document.write(" if (ta.value.length > maxlength){\n"); document.write(" ta.value = ta.value.substring( 0, maxlength );\n"); document.write(" ta.blur();\n"); document.write(" ta.focus();\n"); document.write(" return false;\n"); document.write(" }\n"); document.write(" else {\n"); document.write(" countspan.innerHTML = maxlength - ta.value.length;\n"); document.write(" }\n"); document.write("}\n"); document.write("\n"); document.write("
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How you heard about us:
Full Name:
Address:
City, State, Zip:
Phone:\n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write(" \n"); document.write("
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Email:
Your gender: \n"); document.write("\n"); document.write("
MaleFemale
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Your present age:
Date of birth:
Your height:  
Your current weight:
Your desired weight:
Current level of conditioning:  
Self esteem level:  
Average amount of sleep:  
List any health issues:
Daily water consumption:  
Daily caloric intake:  
All foods eaten in last 2 days:
Foods you dislike or allergic:
Currently exercising: \n"); document.write("\n"); document.write("
NoYes
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If yes, give specific details:
Primary fitness goals: \n"); document.write("\n"); document.write("\n"); document.write("\n"); document.write("\n"); document.write("\n"); document.write("\n"); document.write("\n"); document.write("
Lose weight
Gain weight
Maintain weight
Improve flexibility
Improve endurance
Increase strength
Build muscle
General conditioning
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Do you have a gym membership: \n"); document.write("\n"); document.write("
NoYes
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Exercise equipment you have:
Additional information:
Optional - Upload full body pic:
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