Fit Over 50 Transformation FastTrack Questionnaire

Fit Over 50 Transformation FastTrack™ Personalized Prescription questionnaire

This is the first and MOST IMPORTANT step towards your goals because it helps us understand where you are now, so we can provide a personalized prescription (plan) that gets you where you want to go with speed and certainty.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number*
E-mail*
example@example.com
When is your birthday? *

MonthDayYear
Date
Profession?*
What percent of time do you sit at work? *
T-Shirt Size?*
Emergency Contact Name and Number *
What SPECIFICALLY do you want to accomplish with your health and fitness in the next 6-8-weeks? What are your goals? Write down at least 3 SPECIFIC goals you'd like to see happen over the next 6-8 weeks. *
If we are having this conversation 12 months from now and you were looking back at your progress, what has to have happened with your health and fitness for you to be happy with you progress? What are at least 3 some specific Longterm goals you have?*
If one of your goals is weight loss, how many pounds would you like to lose?

5-15 pounds15-30 pounds30-50 pounds50-100 pounds100+ pounds
How long do you think it would take for you to accomplish these goals on your own?*
Why are these goals important to you? What is your SO THAT? (Example ...I want to lose 15 pounds So THAT I can fit into my clothes again. I want to get healthy SO THAT I can get off my medications.. I want to have energy SO THAT I feel like doing the things I want to do when I get home from work, etc ). Write your top 3 So That's (reasons why you want to achieve your goals). *
What is the most recent thing you've tried to lose weight and/or get in better shape?*

A dietAn exercise programA diet and an exercise program combinedIt's been a long time since I've tried anythingOther
What have you tried in the past and been successful at? Why did it work for you? *
What have you tried in the past and were not successful at? Why did not not work for you?
On a scale of 1(Poor) to 10 (Excellent), how would you rate your current fitness level?*
On a scale of 1(None) to 10 (Most), how would you rate your knowledge of nutrition and eating healthy?*
With the understanding that the more frequently you exercise, the faster you can get results...over the next month, how many days per week can you exercise for at least 30 minutes?*

Just one day per week2-3 days per week4-5 days per week
What do you want to get out of beginning a new, and far more effective, body transformation program?*

I want to look and feel better, more relaxed, confident and present in the momentI want to take control of my health and strengthen my immune systemI want to be a better role model for the people I loveI want to re-ignite the fire in my relationshipI want to feel stronger, more flexible, mobile, balanced and pain-freeAll of the above
What do you feel is the biggest thing standing in your way of becoming the best version of you? What has been your "achilles heel" when it comes to having the body and health you most want to have?*
On a scale of 1 to 10, how do you rate your desire and determination (i.e. commitment) to having the body and health you want to have...even if you've struggled in the past?*
If your commitment level is not a 8, 9 or 10...why not? What's holding you back from having a higher level of commitment to having the health and body you desire?
Which which conditions below have you been treated for? Explain the conditions ......High Blood Pressure, Depression, Hyperthyroid , Heart Attack, Anxiety, Cancer, Irregular Heartbeat, Hyperactivity, Kidney/Bladder, Heart Murmur, ADHD/ADD, Intestinal, Circulatory Problems, Diabetes, Arthritis Digestive Problems, Hypothyroid or Blood/Joint
Are you taking medications? If so, please list them here and why you are taking them
Do you have any other medical issues we need to know about? Do you have any specific concerns or limitations we should know about when prescribing a health and fitness solution for you?
How did you hear about us? A referral is the ultimate endorsement - the ultimate sign of trust. We're so grateful that so many trust us, and we always want to make sure to thank them for their referrals. Please tell us how you heard about our program. If it was from a friend please let us know. *
WAIVER: I agree to participate in the Get You In Shape program. I understand that it is recommended that I consult a doctor before beginning any fitness and/or nutrition program. I acknowledge being informed of the possible risks due to the strenuous nature of the program. Risks may include the musculoskeletal and/or cardiovascular systems and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack, or death. If I feel pain, uneasy, or just not normal, I have been told to consult a doctor immediately. I know of no medical problems that would increase my risk of injury or illness. I recognize that participation in a regular program of exercise has been shown to produce positive changes in a number of bodily systems. These changes include but are not limited to increased work capacity, improved cardiovascular efficiency, and increased muscular strength, flexibility, power, and endurance. By signing this document, I agree to waive, release, and discharge GYIS, Inc, its agents, officers, principals and employees for any and all claims, actions or damages of any kind resulting from participating in GYIS Inc’s programs. I understand that videos and photos will be taken during the fitness sessions and used for promotional purposes. I hereby grant Get You In Shape permission to use my likeness in a photograph, video or other digital media.*

Clear
Anything else that you want to add or share with us? Skip this quick if you don't have anything else
Should be Empty:

Fit Over 50 Transformation FastTrack™ Personalized Prescription questionnaire