<% Response.Buffer = True Response.Expires = -1 '************************************************************** ' Name: header.asp ' ' Type: VBScript ' ' Description: ' ' QueryStrings: ' ' Variables Description ' ===================================================== ' ' Change History: ' ' Date By Description ' -------- ---- ----------- ' memememe '************************************************************** '-------------------------------------------------------------- '******************** `VARIABLES *************************** '-------------------------------------------------------------- dim strRequestStatus dim name dim address dim workphone1 dim workphone2 dim workphone3 dim mobilephone1 dim mobilephone2 dim mobilephone3 dim homephone1 dim homephone2 dim homephone3 dim email dim training dim sex dim feet dim inches dim weight dim docname dim docphone1 dim docphone2 dim docphone3 dim docphone dim ername dim erphone dim erphone1 dim erphone2 dim erphone3 dim drugs dim permission dim cb_pressure dim cb_chronic dim cb_physical dim cb_advice dim cb_surgery dim cb_heart dim cb_dizzy dim cb_baby dim cb_lung dim cb_joint dim cb_diab dim cb_obese dim cb_chol dim cb_hernia dim handicap dim chk_pressure '-------------------------------------------------------------- '******************** GET`VARIABLES *************************** '-------------------------------------------------------------- strAction = Request.QueryString ("strAction") '---- contact info name=Request.Form("name") address=Request.Form("address") workphone=Request.Form("workphone") mobphone=Request.Form("mobphone") homephone=Request.Form("homephone") email=Request.Form("email") training=Request.Form("training") workphone1=Request.Form("workphone1") workphone2=Request.Form("workphone2") workphone3=Request.Form("workphone3") mobphone1=Request.Form("mobphone1") mobphone2=Request.Form("mobphone2") mobphone3=Request.Form("mobphone3") homephone1=Request.Form("homephone1") homephone2=Request.Form("homephone2") homephone3=Request.Form("homephone3") sex=Request.Form("sex") feet=Request.Form("feet") inches=Request.Form("inches") weight=Request.Form("weight") docname=Request.Form("docname") docphone1=Request.Form("docphone1") docphone2=Request.Form("docphone2") docphone3=Request.Form("docphone3") docphone=Request.Form("docphone") ername=Request.Form("ername") erphone=Request.Form("erphone") erphone1=Request.Form("erphone1") erphone2=Request.Form("erphone2") erphone3=Request.Form("erphone3") drugs=Request.Form("drugs") permission=Request.Form("permission") cb_pressure=Request.Form("cb_pressure") cb_chronic=Request.Form("cb_chronic") cb_physical=Request.Form("cb_physical") cb_advice=Request.Form("cb_advice") cb_surgery=Request.Form("cb_surgery") cb_heart=Request.Form("cb_heart") cb_dizzy=Request.Form("cb_dizzy") cb_baby=Request.Form("cb_baby") cb_lung=Request.Form("cb_lung") cb_joint=Request.Form("cb_joint") cb_diab=Request.Form("cb_diab") cb_obese=Request.Form("cb_obese") cb_chol=Request.Form("cb_chol") cb_hernia=Request.Form("cb_hernia") handicap=Request.Form("handicap") chk_pressure = Request.Form("chk_pressure") if strAction = "submit" then Response.Write cb_pressure & "here" 'Initialize variables else ' Form Body Text to be mailed '' strBodytxt= vbfnFormBodyText 'Response.Write strBodytxt ' Send mail message '' vbsubSendMail strBodytxt end if %> Gage Total Taining



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Basic Info



Home  Phone  
Work Phone  
Mobile Phone  

Basic Health History




ft. in.

Current Weight:  



Current Weight:  


Doctor's Name:  
Doctor's Phone:  
Person to Contact in  Case of Emergency:  



Are you taking any medications/drugs? If so, please list medication, dose and reason:

Does your doctor know you are participating in this exercise program?

Yes No

Check what applies to you (past or present): 
Increased blood pressure Pregnancy (now or within last 3 months) 
Any chronic illness or condition History of breathing or lung problems
Difficulty with physical exercise

Muscle, joint or back disorder, or any previous injury still affecting you

Advice from physician not to exercise Diabetes or thyroid condition
Recent surgery (last 12 months) Obesity (more than 20  percent over ideal body weight)
History of heart problems in immediate family Increased blood cholesterol
History of dizziness, blackouts or balance problems
Hernia, or any condition that may be aggravated by lifting weights
If you checked anything above, or if you have any other health issues, please explain:

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