“Senior Wellness Survey”
Helping The Next Generation of Seniors
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Gender
Male
Female
Do you have any past injuries?
Yes
No
How often do you exercise ?
1-2 Days
2-3 Days
3-4 Days
4-5 Days
Which type(s) of exercise do you enjoy?
Weight Lifting
Yoga/Pilates
HITT
Conditioning
What area(s) of health are you seeking to improve?
Strength
Stability
Mobility
Functionality
Coordination
Select your current fitness level ?
Committed to Structure
Self Accountability
A little guidance needed
Help
Which class(es) are you interested in joining ?
Houston O Park(Monday 11:00 AM)
Israel Church of Jesus LA (Tuesday 11:00 AM)
Security Missionary Baptist (Wednesday 11:00 AM)
2nd Mt.Carmel Missionary (Thursday 11:00 AM)
Do you need special attention in any of these areas?
Diet Strategy
Rest Strategy
Positive Energy Strategy
Stress Management Strategy
Submit
Want to learn more about us? Visit
www.5keyfitness.com
and click on the Senior Wellness tab.
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