YOUR LIFE QUESTIONNAIRE

The following information is about:
Me My Child

Full Name:

Phone:

E-mail:

Referred by (if applicable):

Age:

Sex: M F

Height: 3 4 5 6 7 ft 1 2 3 4 5 6 7 8 9 10 11 in

Current Weight: Desired Weight:

Body Fat % (if known):

PRIMARY Bodyweight Priority: Lose Weight Maintain Weight Gain Weight

Exercise History

I currently engage in an exercise program: Y N

If yes, how many sessions per week?

How long, on average, are these sessions? 30 minutes 45 minutes 1 hour 1 hr 15 min 1 hr 30 min 1 hr 45 min 2+ hours

What is the level of intensity (1-10)?

Physical activities I currently engage in are:

My activity level at work is: Largely inactive (desk job, driver) Lightly active (teacher, homemaker) Heavily active (construction, labor) other

If other, please describe:

My previous background in sports/physical activities is:

This is the main reason I am pursuing an exercise program with The Fitness Difference:

I have questions or concerns about commencing a new exercise program. Y N

If Yes, explain:

Out of the list below, what are the most important for you to achieve through an exercise program? (choose all that apply)

Feel healthier

Reduce body fat

Increase energy level

Improve strength

Improve muscle size

Improve muscle tone

Improve aerobic capacity

Improve flexibility

Improve ability at specific sport

Improve ability to cope with stress

Improve social life

Improve overall quality of life

The types of exercise that most interest me include:

I have the most energy in the morning afternoon evening

I could use some help with my eating program. Y N

Additional comments concerning my exercise program:

The program I am interested in In-Home Single Session - $69 In-Home 4 Session - $248 (10% Discount) In-Home 8 Session - $442 (20% Discount) I'm not quite sure. I need more info.

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