Rough-Fit
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Welcome
to the Wellness in Total Health University
Step 1
Step 2
Step 3
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Step 5
Step 6
Step 1 - User Details
Preferred Name:
Initials:
First Name:
Middle Name:
Last Name:
E-Mail:
Registration Code:
Register with:
Register in Group:
Preferred User Name:
Preferred Password:
Step
2
- Profile Details
Date of Birth:
Weight:
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Height:
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Gender:
Male
Female
Physical Address:
City:
State:
Zip:
Country:
Home Phone:
Office Phone:
Mobile Phone:
Fax Number:
Step
3
- Emergency Contact Details
First Name:
Last Name:
Contact Number(s):
Relationship:
Step
4
- Exercise Programs
Payment Method:
Check
Paypal*
* 5% additional charge for PayPal
Add / Select
Exercise Program
One Time Cost
Monthly Cost
1:1 Remote Training with workout program 4-week se
0.00
105.00
Results 1:1 Program - $80/session
80.00
0.00
Rough-Fit Results 4 Week ANYTIME program
0.00
125.00
Rough-Fit Results 4 week ANYTIME program Annual
0.00
105.00
Yoga in the Park
0.00
45.00
Step
5
- Questionnaire
Question
Answer
Explaination if answer is "Yes"
Breathing or lung problems?
Yes
No
Does your physician approve of your participation in an exercise program?
Yes
No
Medications that might affect your vital signs or physical performance?
Yes
No
Muscle, joint or back disorder, or any previous injury still affecting you?
Yes
No
Hernia or any condition that might be aggravated by lifting weights?
Yes
No
Recent surgery (last 12 months)?
Yes
No
Any chronic illness or condition?
Yes
No
Increased blood pressure?
Yes
No
Increased total blood cholesterol (200 mg/dL)?
Yes
No
Heart problems in the immediate family?
Yes
No
Obesity (more than 20% over ideal body weight)?
Yes
No
Heart problems, chest pain or stroke?
Yes
No
Cigarette, cigar or pipe smoking habit?
Yes
No
Step
6
- Waiver
I Agree
Registration successful
Thank you for registering!
Your Username and Password was e-mailed to
Label
July 2010
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