Personal Fitness Survey
Please complete the form below so we can have a better idea of how to best meet your needs. We will contact you soon after receiving the form results.
About You
1. Name:
2. Email Address:
3. Phone (optional):
4. Gender
Male
Female
5. Age range
18-25
26-35
36-45
46-55
56-65
Over 65
6. Where do you live
City:
State:
7. height/weight
height:
weight:
8. Current condition of your body
Under-weight
Average
Slightly overweight
Over-weight
Greatly over-weight
9. Do you have high blood pressure, asthma or other chronic breathing problem, back problems, arthritis or other condition that could interfere with your ability to exercise?
Yes
No
10. Do you smoke?
Yes
No
11. Are you currently taking any medication that could interfere with your ability to exercise strenuously?
Yes
No
Current exercise habits
12. Approximately how many minutes per week do you currently spend in some type of strenuous exercise?
Less than an hour per week
60-90 minutes per week
90 minutes – 2 hours per week
2-3 hours per week
More than 3 hours per week
13. How often to you engage in exercise that raises your heart rate and causes you to sweat for at least 10 minutes?
Almost never
1-2 times a week
3-4 times a week
More than 4 times a week
14. How often do you engage in exercise that helps you increase in muscle flexibility.
Almost never
1-2 times a week
3-4 times a week
More than 4 times a week
15. How often do you engage in exercise that helps you build muscle?.
Almost never
1-2 times a week
3-4 times a week
More than 4 times a week
16. Do you generally consider exercise to be fun and relaxing?
Yes
No
Your Goals
17. Select the fitness goals below that are important to you (choose 2-3)
Other Goals:
18. If you had to choose one physical fitness goal to attain in the next 4 months, what would it be.
Lose 10 pounds
Improve cardiovascular health
Lose 2 inches off my waist
To feel more healthy
Establish a personal fitness plan and regimen
19. Which of the following would you most likely consider doing in order to reach your personal fitness goal(s)?
Pay for a personal trainer
Pay for a gym membership
Look for free online fitness information
Purchase an in-home exercise machine
20. Which areas of personal fitness do you need the most help with? Choose 2 or 3
Other:
21. Have you ever hired a Personal Trainer before?
yes
no
22. What has typically been the hardest part about staying in shape?
Hard to find time
I dont like to exercise
I cannot keep up the discipline
Physical pain, injury, sickness prevents me from exercising
Home
Kettlebell Workout
About Us
Services
Fitness Assessment
Pay Online
Contact
