Health and Fitness Survey
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Please provide us with your contact information: Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:

Please list your fitness goals.

How many days per week do you exercise now?

If you exercise, please list what activities you currently do.

What exercises do you like, both indoor and outdoor?

What exercises will you NOT do?

Would you attend a nutrition/cooking class? Yes

Would you attend a support group for fitness and weight loss encouragement? Yes

Describe any physical limitations you may have due to surgeries or injuries.

Do you have any other medical conditions that need to be taken into consideration when exercising? Arthritis

Back problems

Epilepsy

Hypoglycemia

Osteoporosis

Other (please specify)

How do you best learn and retain information? Auditory (listen to instructions)

Visual (want photos of exercises)

Tactile (learning by doing)

What time of the day would work best for you to attend exercise class, nutrition/cooking class, support group?

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Health and Fitness SurveyExit this survey