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Let us create a personalized fitness program just for you.
We have provided a comprehensive questionnaire for you to fill out in order to evaluate which of our custom fitness programs is right for you! If you have any questions, contact your Clinical Assistant or call 800-466-2209 and ask to speak with one of our Fitness Specialists.

1. Contact Information:
First Name:
Last Name:
E-mail address:
Address 1:
Address 2:
City:
State:
Zip Code:
Home Phone: (Include area code)
Bus. Phone: (Include area code)
Occupation:
2. General Information:
Gender: Male: Female: Height: Date of Birth:
Current Weight: Desired Weight:
Bone Structure:    Small     Medium     Large
Activity Level:     Very Low     Low     Medium     High     Very High
Do you smoke?    No     Yes     If Yes, cigarettes per day
Do you drink alcohol?    No:     Yes:
If Yes, what is your consumption?
Beer: oz./week   Wine: oz./week   Liquor: oz./week
3. Fitness Goals
Increase Muscle Reduce Fat level Tone Up Increase Energy
Areas you would like to focus on:
Number of days per week available for training:
4. Training Schedule
Which days of the week would you like to weight train?
Mon / Tue / Wed / Thur / Fri / Sat / Sun
How much time can you devote to each weight training session?
30 min. 45 min. 60 min. Other:
What type of cardiovascular exercise do you prefer?
Cycling Stepper Treadmill Running Other:

What training methods worked best for you in the past?

List any other information that you consider relevant:

5. Dietary Habits
No
Yes
  
Have you tried dieting before?
   If Yes, What have you tried?
Are you allergic to any foods?
   If Yes, What are your food allergies?
Do you have a lactose intolerance?
Are there any foods you refuse to (or do not) eat?
    If Yes, please describe:
Which of the following meals do you currently eat, and at what time do you eat them?
Breakfast Time Morning Snack Time
Lunch Time Afternoon Snack Time
Dinner Time Evening Snack Time
NoYes  
Prefer protein (meat, fish, poultry, etc.)?
Prefer carbs (pasta, rice, potatoes, fruits, sweets, breads, etc.)?
Prefer fats (sauces, butter, fried foods, bacon, sausage, etc.)?
Please indicate any regular eating habits you have (i. e. dining out on weekends,
late night eating, cravings, etc.):
Please list ALL the foods you have eaten in the last forty-eight hours:
How many 8 oz. glasses of water (excludes soda, coffee, tea, etc.)
do you drink each day? Enter Average per Day:
How many meals per day do you eat? 3 4 5 6 7

Do you have any comments, questions, or concerns regarding the programs?

DISCLAIMER
The Health & Rejuvenation Center is not responsible for any injury or harm incurred by following an unsupervised program. Please consult a physician before beginning any strenuous exercise program.

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CLINIC LOCATION / MAILING ADDRESS:
Gardens Medical Park, 3345 Burns Road, Suite 204, Palm Beach Gardens, Florida 33410
(Located 5 minutes south of I-95 and PGA Blvd. directly across from Gardens Medical Center)
PRESCRIBING PROCEDURES LEGAL COMPLIANCE | ABOUT OUR MEDICAL DIRECTOR
No prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current medical history provided either through a patient's personal physician or an associate physician of The Health & Rejuvenation Center (THARC.COM). Agreeing to lab work does not automatically equate to clinical necessity or a resulting prescription. No claim or opinion on the THARC network is intended to be, or should be construed to be, medical advice. Please consult with a healthcare professional before starting any therapeutic program.

Questions or Concerns? Having problems with your therapy?

Call our Patient Service Hotline at (561) 847-2489

© 2004-2008 The Health & Rejuvenation Center. All Rights Reserved.
3345 Burns Road, Suite 204, Palm Beach Gardens, Florida 33410
(561) 340-1580 • Fax (561)340-1581

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