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First & Last Name  

Address  

   

City  

State  

Zip Code  

     
Email Address  

Daytime Phone  

Evening Phone  

     

Name of Friends/Family You Would Like To Get Fit With:

 

How much time will you be devoting to a healthier lifestyle per week?

 

Are you willing to forego the cost of a cup of coffee, soda or a candy bar
on a daily basis to fund your healthier body?
Yes    No
 

Is your spouse supportive of your desire to improve your well being?
Yes    No
 

Would an improvement in your health affect your family?

Yes    No
If yes, how? 

 

What was the last thing you have done for yourself?

 
What areas of your body would you like to focus on?
Waist   Hips   Thighs   Chest   Arms   Glutes
 

On a scale from 1 to 10 (10 being most important), please rate the following:
Safety     1   2   3   4   5   6   7   8   9   10
24 hr Access    1   2   3   4   5   6   7   8   9   10
Sunday Access    1   2   3   4   5   6   7   8   9   10
Tanning     1   2   3   4   5   6   7   8   9   10
New Equipment   1   2   3   4   5   6   7   8   9   10
Personal Trainer     1   2   3   4   5   6   7   8   9   10

Shower Facilities

   1   2   3   4   5   6   7   8   9   10

Anytime Fitness Murfreesboro, TN
(next to Hastings)
1648 Memorial Blvd.
Murfreesboro, TN 37129