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First Name

Middle Initial

Last Name

State

Zip

Home Phone

Business Phone

Mobile

Please check the number at which you would prefer us to contact you.

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1 History of heart problems, recurring chest pain, heart murmur, or stroke Yes No

2 Diagnosis of hypertension or take medicine for same Yes No

3 Diabetes Mellitus Yes No

4 Asthma, breathing or lung problems Yes No

5 Cancer (other than skin) Yes No

6 Seizures, seizure medication, neurological problems or severe dizziness Yes No

7 Gallbladder disease or intestinal problems Yes No

8 Back problem, joint or muscle disorder still affecting you Yes No

9 Recent surgery (last 12 months) Yes No

10 Hernia or any condition that may be aggravated by lifting weights Yes No

11 Physician's advice not to exercise Yes No

12 History of total Cholesterol greater than 240 mg/dl Yes No

13 Family history of coronary heart disease or other atherosclerotic disease in parents or siblings before age 55 Yes No

14 Are you pregnant, lactating or anticipating becoming pregnant? Yes No

If your answer is YES to any question above, give brief explanation:

14 History of cigarette smoking Yes No

If your answer is YES, give smoking history:

14 Do you take vitamins? Yes No

14 Are you allergic to soy? Yes No

14 Are you allergic to lactose / dairy products? Yes No

14 Are you taking any medications? Yes No

If so, what?