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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Contact Phone

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* 5. Preferred method of contact

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* 6. How did you hear about us

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* 7. What are the main reasons you are interested in Personal Health Coaching, check all that apply

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* 8. How many days a week do you exercise

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* 9. On an average day, how much time do you spend doing physical activities with family or friends, ie sports, running, walking, biking, hiking,

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* 10. Using the scale below, how much time daily do you spend doing the following:

  Less than 30 minutes a day 30 to 60 minutes a day 1 to 2 hours a day 3 to 6 hours a day Over 6 hours a day N/A
Reading
Using a computer
Using your smart phone applications, ie Facebook, News, Internet, etc.
Watching TV
Sleeping

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