Worlds Best Trainer
1 Tuxedo Drive
Melville, NY 11747
Please Make Check or Money Order Payable to
George Baselice
Check
Product Name
Price
...Total...
George's Diet
$20.00
$
George's Workout
$20.00
$
Carmela's Diet
$20.00
$
Carmela's Workout
$20.00
$
Bowflexercise & The Turning
Point Book
$24.95
+$5.00
S&H
$
Check/Money
Order Only
Total
$
Name
Address
E-mail Address
If
Ordering Customized Workout, PleaseFill in as much as
possible.
Name:
Address:
E-mail Address:
Home Phone:
Physician's Name:
Phone:
Date of last physical
examination:
Resting Heart Rate:
Height:
Weight:
Bodyfat:
Age:
Birthdate:
Blood Pressure:
Measurements:
Shoulders:
Thigh:
Calf:
Waist:
Hips:
What are your fitness goals?
Weight
(fat) loss
Gain
Weight (muscle mass)
Improve
eating habits/overall health
Have you ever been in a
structured weight loss program ?
NO
YES
(explain)
Health History:
YES
NO
UNSURE
Do you smoke?
Has your doctor ever said you blood
pressure was too high/low?
Has your cholesterol level was to high?
Do you have any injuries or orthopaedic
problems(bad back)?
Have you ever taken any prescribed
medications or dietary supplements?
Are you currently involved in a regular
exercise program?
Have you ever had or currently have
any of the following conditions. Check any that apply?
YES
YES
YES
YES
Heart Disease
Hypertension
Hypotension
Diabetes
Liver Disease
Bulimia
Headaches
Asthma
Anemia
Hypoglycemia
Angina
Croh's
Flatulence
Pancreatic Disease
Bloating after meals
Anorexia
General Health & Nutrition
What type of supplements and how
are they delivered?
Do you have any other medical
conditions? Explain.
Rate your health.
Excellent
Good
Fair
Rate your activity lavel at
work.
Sendentary(desk
job)
Active
Extremely
Active
How often do you currently exercise?
Week
How long is each session?
Hours
Total hours a week?
Hours
Do you have any other medical condition
or problem not previously mentioned?
What are your goals with this program?
Additional comments:
What have you eaten in the last three days.
Day 1
Day 2
Day3
Consent Form:
Signature:
Date:
*I acknowledge, to the best of my ability, that
I am in good health and have no known medical problems that
would restrict my ability to participate in this exercise
program. I am committed to making a positive change in my
health through my participation in the program. I understand
that certain aspects of this program can be physically
demanding. I also understand that I will need to change
various aspects of my life in order to obtain the goals I have
set forth. As a condition of my enrollment, I accept full and
complete responsibility for my own ability to healthful
participation in this program. This means I acknowledge that I
should obtain a physicians approval of my participation in
this program. I agree to hold George Baselice/Carmela Baselice
and the facility of World's Best Trainer/worldsbesttrainer.com
employees, shareholders, successors and assigns free from any
and all liability in connection with my performance or medical
conditions that might arise. I willingly and knowingly assume
for myself and my heirs executors, administrators and assigns
any risk which is associated with my participation in this or
any program related to World's Best Trainer/worldsbesttrainer.com
