Your Name (First Last):

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Phone Number:

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Fitness

Male

Your weight in kilograms:

Are you disabled? Yes No

How often do you exercise?

(times per week)

If 'Yes' which of following applies to you?

Hearing Impairment Visual Impairment Spinal Cord Injury Heart Conditions Respiratory Conditions Chronic Injuries Back Pain Tendonitis

Which sports do you like? Football Basketball Tennis Swimming Running Aerobics Body-building Cycling Spinning Squash Weight Training Jogging

Your age (years):

Is there anything else you would like to add about yourself?

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