Lifestyle/Goals Questionnaire Full Name* Phone Number*Email Address* 1. What is your purpose in participating in an exercise program? What is your overall goal?2. How long do you believe it will take you to attain your overall goal? 3. How many minutes per day do you spend doing exercise? 0 1-15 30-60 61-90+ 4. How many days per week do you exercise?5. What types of activities do you do when you exercise? 6. How many days per week can you commit to an exercise program?7. How many minutes per day can you commit to an exercise program? 8. What activities would you prefer in a regular exercise program for yourself? Walking and/or running Swimming Basketball Tennis Jumping rope Volleyball Bicycling/spinning Handball/racquetball Group exercise 9. What are your personal barriers to exercise?10. How physically fit are you? Not Below average Average Above average Outstanding Don't know 11. What is your occupation? Is your occupation: Sedentary Semi-active Active 12. Indicate the main reason why you exercise. I do not exercise It is good for my health It makes me feel good I am required to exercise I'm trying to lose weight My doctor told me to exercise 13. Do you frequently participate in competitive sports? yes no If yes, please list:14. Did you or do you participate in high school or college athletics? yes no If yes, please list:15. How many successive hours of restful sleep do you have per day? 16. How would you describe your quality of sleep? Dietary Patterns17. Do you feel you eat healthy most of the time? 18. How many meals and/or snacks do you eat per day? 19. Do you eat breakfast? yes no 20. How many servings of the following do you partake of each week?Red meat and eggs Fish Fried foods Poultry Vegetables Fruit Alcohol Caffeinated beverages Carbonated beverages 21. How much water do you consume each day?in ounces22. Is there anything else that we need to know in order to help you attain your goal?How Did You Hear About Us? Google Search Facebook Instagram Referral Print Marketing Sign/Van Who referred you? PhoneThis field is for validation purposes and should be left unchanged. Δ
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