YOUR LIFE QUESTIONNAIRE

CURRENT OPENINGS: THURSDAYS: 10:00 AM in Gladstone/Oak Grove area.

NOTE: I work with women and children, but not with men alone. I work with men only in a spousal or family setting. Thank you for your understanding.

The following information is about:
Me My Child

Name:

Phone:

Type e-mail twice:

E-mail:

E-mail:

Referred by (if applicable):

Age:

Sex: M F

Height: ft in

Current Weight: Desired Weight:

Body Fat % (if known):

PRIMARY Bodyweight Priority:

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?

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

Physical activities I currently engage in are:

My activity level at work is:

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

I could use some help with my food choices. Y N

Additional comments concerning my exercise program:

The program I am interested in

By clicking the submit button, you are confirming that you are 18 or over. If you are under 18, a parent or legal guardian must give their express consent prior to services being rendered.

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*Fitness results will vary from person to person.