Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Has your doctor ever advised against exercise? *

Yes

No

Do you smoke? *

Yes

No

Are you pregnant or postpartum? *

Yes

No

N/A

What is your current stress level? (Low / Medium / High) *

Low

Medium

High

What are your primary fitness goals? *

Weight Loss

Muscle Gain

General Health

What types of training are you interested in? (Check all that apply) *

Strength Training

Cardio Fitness

Weight Loss / Fat Loss

Muscle Gain

Mobility / Flexibility

Stress Relief / Mindfulness

Other:

Do you have access to a gym or workout equipment? *

Yes

No