Name *

First Name

Last Name

Phone *

(###)

###

####

What's the activity level at your job? *

Sedentary (seated only)

Moderate (light activity such as walking)

High (heavy labor, very active)

How often do you travel? *

Rarely

A few times a year

A few times a month

Weekly

Are you experiencing any stresses or motivational problems? *

Yes

No

Are you a current cigarette smoker? *

Yes

No

Your current diet could be best characterized as: *

Low-fat

Low-Carb

High-protein

Vegetarian/Vegan

No special diet

Please rate your readiness for change. *

1 Just Thinking About It.

2

3

4

5

6

7

8

9

10 Ready to do whatever it takes.

What following goals best fit in with your goals? *

Improved health

Improved endurance

Increased strength

Increased muscle mass

Fat loss

What timeline do you have for achieving your goal: *

8 Weeks

16 Weeks

24 Weeks

32 Weeks

40 Weeks

1 Year

Please rate your motivational level to do what it takes for reach your goal. *

1

2

3

4

5

6

7

8

9

10

Are you currently exercising regularly (at least 3x per week)? *

Yes

No

Have you trained with a personal trainer before? *

Yes

No

At what times during the day would you prefer to train? *

Morning

Mid-Day

Afternoon

Evening

How often do you want to utilize Personal Training or Fitness Classes each week? *

1 Day

2 Days

3 Days

4 Days

5 Days

6 Days

7 Days