Consultation “Get To Know You” Survey Question Title * 1. Please fill out the following: First and Last Name Birthday MM/DD/YYYY Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. Which best describes your overall fitness/health goals? Fat Loss Muscle Gain General Health/Maintenance Performance Based/Sports Performance Other, or a combination of the above options (please specify) Question Title * 3. What are your health/fitness goals? They can be short term, long term, general, or specific – and it does not have to be number related!! (Ex. “I want to be able to run a 5k by 2019” vs. “I want to lose 30 lbs.”) Question Title * 4. Do you have any past experience with working out/sports/training, etc? If so, please explain: Question Title * 5. What, if anything, do you think has prevented you from reaching your goals/motivating you in the past? Question Title * 6. Do you have any injuries or illnesses that may limit exercise or range of motion? All Done!