Questionnaire

Today's Date *

Name *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Age *

Email *

Height *

Ft/In

Current Weight *

lbs

What is your primary fitness goal for this challenge? *

If "other", please explain:

What are you hoping to gain from this program? *

Do you smoke? *

Do you drink alcohol? *

Do you have any current or previous medical conditions or injuries? Medications? *

On a scale of 1-5 (1 being poor, 5 being excellent) How have you been feeling mentally with your current exercise & nutrition routine? *

On a scale of 1-5 (1 being too easy, 5 being extremely challenging) How challenging do you find your workouts? *

Will you be working out at home or the gym? *

What is your current workout routine? *

Additional comment/questions/feedback? *

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