First & Last Name

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?

2 visits per week 3 visits per week 4 visits per week 5 visits per week 6 visits per week 7 visits 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:

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

Shower Facilities

1   2   3   4   5   6   7   8   9   10