Questionnaire (Silver Tier) First Name Last Name Email Sex Male Female 1) What are your specific wellness goals? 2) To the best of your knowledge, what is your current height? 2) To the best of your knowledge, what is your current weight? 3) What is your goal weight 4) What is your target goal date? 5) Do you take any vitamins or supplements? Yes No If “Yes”, list items: 6) Do you smoke? Yes No 7) How many days can you workout? 1 2 3 4 5 6 7 8) What is your exercise level? Beginner Intermediate Advanced 9) Please select your age range: 18-39 40-59 60+ 10) Do you have any condition that would require a doctor’s clearance? Yes No If “Yes”, please specify: 11) Do you experience any of the following during physical activity? Lost of balance Dizziness Lost of consciousness Chest pains Shortness of breath None 12) Do you have an existing or previous injury that may affect how you perform physical activities? Upper Body Lower Body None If “Yes”, please specify: 13) Are you prescribed medication for blood pressure or a heart condition? Yes No If “Yes”, please specify which condition: 14) Are you, or have you recently been pregnant? Currently Pregnant Recently Pregnant Neither 15) Do you have access to a gym? Yes No List gym equipment that you have at home. 16) Check all that applies on your health and fitness goals. Gain Muscle Lose Fat Maintain Current Weight Get Ripped Improve Overall Health Leave a comment(Optional) I agree to receiving marketing and promotional materials Submit
