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?01-1530-6061-90+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?NotBelow averageAverageAbove averageOutstandingDon't know11. What is your occupation?Is your occupation:SedentarySemi-activeActive12. Indicate the main reason why you exercise.I do not exerciseIt is good for my healthIt makes me feel goodI am required to exerciseI'm trying to lose weightMy doctor told me to exercise13. Do you frequently participate in competitive sports?yesnoIf yes, please list:14. Did you or do you participate in high school or college athletics?yesnoIf 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?yesno20. How many servings of the following do you partake of each week?Red meat and eggsFishFried foodsPoultryVegetablesFruitAlcoholCaffeinated beveragesCarbonated beverages21. 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?EmailThis field is for validation purposes and should be left unchanged.