Ironsmith Online - Intelligent Training, Smart Results @ fitnessdoctors.com

Ready to get started?

How did you hear about Ironsmith?
If referred by a friend please enter their name below, or else enter N/A: (required)
If referred by a Physician please enter their name below, or else enter N/A: (required)
Drove By	Nelo's Pro Cycles
Outdoor Signage	Austin Fit Magazine
Television	Austin Tricyclists
Radio	Wang Newsletter
K.U.T. Radio	Direct Mail
Southwestern Bell Phone Book	Tribeza Magazine
Ironsmith e'Fit Report	Ironsmith Tri Fit USA Report
Other:

Tell us about yourself:
Name:	(required)
Occupation:
Age Range:
Date of Birth:
Phone (W):
Phone (H):	(required)
Address:	(required)
City:	(required)
State:	(required)
Zip:	(required)
Primary E-mail:	(required)
Secondary E-mail:	(required, please enter primary e-mail if no secondary e-mail is available)

Lifestyle/Daily Activity Routine: (Describe a typical day from waking to sleep)

Activity History: (Have you ever exercised before? If yes, what type and how often?)

Injuries or Health Concerns:
Spinal Stabilization	Disc Herniation
Post Partum	Rotator Cuff Tear
Hypertension Exercise	Impingement Syndrome
Post Surgical: Knee/Back/Shoulder	Cervical Spine
ACL Rupture/Reconstruction	Lower Back Pain
Total Knee Replacement	Diabetes
Degenerative Joint Disease	Functional Training
Total Hip Replacement	Patello-femoral Syndrome
Spinal Stenosis	Meniscal Tear
Please give us more details on any box checked:

Do you have any reason to believe you should not exercise?

Desired Changes/Goals:
Professional Resistance/Strength Training	Yoga Classes - Individual Sessions & Classes
Sports-Specific Performance Enhancement	Medical Exercise for Disease Management
Cardiovascular Training	Senior Conditioning
Professional Fitness Training	Cardiac Rehabilitation
Running Improvement	Physical Therapy
Cycling Improvement	Post Surgical Rehabilitation
Swim Training	Weight Reduction
Flexibility Training	Balance/Coordination
Sports Injury Prevention	Pilates
TRIFIT USA Triathlon Training
Goals/Changes:

Long Term Goals (6-12 months):

Short Term Goals (0-6 months):

Additional Comments:

Ironsmith - The Fitness Doctors
4800 Burnet Rd. Bldg A STE 100
Austin, Texas 78703
512.454.4766
E - mail: info@fitnessdoctors.com