Name

E-mail Address

Address

City

State

Zip

Daytime Phone with area code

Age

Male Female

Occupation

Describe Your Activity Level
(activity suggests daily movement other than structured exercise
and may include physical labor at work or recreational sports)

Describe your Exercise Goals:

Describe your exercise history:

Describe your primary challenges, frustrations,
or obstacles in achieving your fitness or weight loss goals:

Describe any physical limitations or medically diagnosed concerns: