Name First Last PhoneEmail Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthday Date Format: MM slash DD slash YYYY Height (inches)Weight (pounds)Emergency Contact Name First Last PhonePrimary Care Physician First Last May we contact your primary care physician regarding your case? Yes No Will you allow bioDensity to use your data for research? Yes No Do you currently engage in exercise on a regular basis? Yes No What is your physical activity like on an average day? Not Active Moderately Active Very Active Describe physical activity in a normal day:How healthy do you consider yourself to be? Not Healthy Moderately Healthy Very Healthy Check if you have ever been diagnosed or experienced any of the following: Current Pregnancy Pulmonary Embolism Acute Hernia Spinal Disc Injury Acute Thrombosis Neurological Disorders Migraines Epilepsy Cardiovascular Disease Recent Infections Pacemaker Implantable Defibrillator Cancer Tumors/Polyps Retinal Conditions Metal Pins/Plates Joint Replacement Recent Operation High Blood Pressure High Cholesterol Low Bone Density Diabetes Blood Clotting Stroke Describe your history of exercise in detail, from as young as you can remember until present day:Describe your history of diet and nutrition:List and explain any musculoskeletal injuries, surgeries, or problems you have ever experienced:What is your main purpose for interest in this program?