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* 1. At what email address would you like to be contacted?

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* 2. How ready do you feel to change your eating and exercise patterns and/or lifestyle behaviors? On a scale from 0-10 (10 being the most ready)?

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* 3. How would you like your health and fitness level to be different? How is your current health and/or weight affecting your life right now?

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* 4. What would it mean for you if you to be healthier? For your life's goals and relationships?

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* 5. What is your height and weight currently? Your BMI?

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* 6. What would make you more confident about making changes? How can we help you overcome any barriers to your success?

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* 7. Can you dedicate 20 minutes a day to a program with Life Balance Fitness for the next 14 days to make these changes?

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* 8. What is your resting heart rate? __________ (count for 10 seconds and multiply by 6)

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* 9. What is your occupation? Does it cause you any mental stress or anxiety? How long to you sit during a week? Do you have any repetitive motions that are part of your typical day? And do you wear high heal shoes?

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* 10. How often do you exercise and what do you currently do? Also what are your recreational hobbies (reading, gardening, working on cars, golf, skiing, etc.)

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