New Client Questionnaire

* Full Name :

* Age :

* Address :

:

* City :

* State :

* Zip :

* Phone :

* Email Address :

* What is the activity level at your job?

None (seated only)

Moderate (light activity such as walking)

High (heavy labor, very active)

* If you have any diagnosed health problems or injuries, list the condition(s).

* Your current diet could be best characterized as:

* What is your goal weight and body percentage?

* Which of the following best describes your fitness goal?

* Timeline for achieving your goal?

3 Months

6 Months

9 Months

1 Year

* How many days are you willing to train a week to reach your goal?

One

Two

Three

Four

* Please rate your motivational level to do what it takes for reach your goal.

* Do you travel? If so, what is your ideal destination?