Demographics

DEMOGRAPHICS
ETHNICITY

WhiteHispanic LatinoAfrican AmericanNative AmericanAsian Pacific IslanderOther
# OF CHILDREN

012345 or More
YOUR AGE

Under 1819 - 3031 - 4041 - 5051 - 6061 or More
GENDER

MaleFemale
HEIGHT
WEIGHT
MARITAL STATUS

Single, Never MarriedSingle, DivorcedMarried, Domestic PartnerMarried, Non-Domestic PartnerSeparatedWidowed
HIGHEST LEVEL OF EDUCATION

High School, No DiplomaHigh School, DiplomaTrade or VocationalCollege, No DegreeAssociates DegreeBachelor’s DegreeMaster’s DegreeDoctorate Degree
EMPLOYMENT STATUS

Self EmployedCompany EmployedOut of WorkStay at Home ParentStudentMilitary EmployedRetiredUnable to Work
DID YOU PLAY SPORTS IN HIGH SCHOOL?

YesNo
IF SO, LIST ALL THE SPORTS
DID YOU PLAY SPORTS IN COLLEGE?

YesNo
DID YOUR MOTHER PLAY SPORTS IN COLLEGE?

YesNo
DID YOUR FATHER PLAY SPORTS IN COLLEGE?

YesNo
IF SO, LIST ALL THE SPORTS
IF SO, LIST ALL THE SPORTS
IF SO, LIST ALL THE SPORTS
HEALTH BACKGROUND & HISTORY
DO YOU HAVE ASTHMA?

YesNo
EVER HAVE PROBLEMS GETTING OXYGEN DURING EXERCISE?

YesNo
HAVE YOU HAD PHYSICAL SURGERY BEFORE?

YesNo
HAVE YOU HAD PHYSICAL THERAPY IN THE PAST?

YesNo
HAVE YOU IN THE PAST, OR CURRENTLY SMOKE CIGARETTES?

YesNo
HAVE YOU IN THE PAST, OR CURRENTLY SMOKE CIGARS?

YesNo
HAVE YOU IN THE PAST, OR CURRENTLY SMOKE A VAPOR?

YesNo
DO YOU CURRENTLY HAVE ANY NASAL ALLERGIES?

YesNo
WHAT PHYSICAL RESTRICTIONS OR LIMITATIONS ARE YOU CURRENTLY EXPERIENCING?

Joint Flexion LimitationBone Spurs or ContusionTendon TightnessMuscle Soreness or InflammationEarly FatigueLack of Overall Flexibilty
ARE YOU ALLERGIC TO ANY FOODS OR MEDICATIONS? IF SO, PLEASE LIST THEM HERE.

YesNo
LIFESTYLE
HOW WOULD YOU DESCRIBE YOUR CURRENT JOB WORKFLOW?

Laid-backDemandingSeverely IntenseUnbearable
WHAT PERCENTAGE OF TRAVEL DOES YOUR JOB REQUIRE?

0%10-20%30-40%50-60%70% or More
HOW WOULD YOU CATEGORIZE THE STRESS LEVELS AT WORK?

Very LowModerateHighly StressfulAgonizing at Times
RATE YOUR QUALITY OF SLEEP?

Very PoorFairly DecentGoodExcellentNot Sure
RATE YOUR ENERGY IN THE MORNING?

LowModerateHighAnxiousExcited-Stressed
ARE YOU TAKING ANY MULTI-VITAMINS?

YesNo
ARE YOU TAKING SUPPLEMENTS?

YesNo
HOW MANY MEALS DO YOU EAT PER DAY?

12345
IF YES, WHAT BRANDS
IF YES, WHAT BRANDS
HOW MANY TIMES PER WEEK DO YOU EAT OUT?

12345
DO YOU COOK YOUR OWN FOOD?

RarelySometimesVery FrequentlyEveryday
HOW OFTEN DO YOU EAT BREAKFAST?

Rarely1 Day Per Week2 Days Per Week3 Days Per WeekEveryday
TIME OF DAY YOU EAT SNACKS?

10 - 11 am12 - 1 pm2 - 3 pm4 pm
THE LATEST YOU EAT MEALS AT NIGHT?

678910
LIST THE AREAS OF NUTRITION YOU WOULD LIKE TO IMPROVE IN?

Eating BreakfastLess Fat FoodsMore Home CookingLess Eating OutMore Organic FoodsMore Healthier FoodsMore Balanced Meals

HOW WOULD YOU RATE YOUR OVERALL NUTRITIONAL HEALTH?

	1	2	3	4	5	6	7	8	9	10

1 is Poor, 10 is Excellent

EXERCISE
# OF DAYS A WEEK YOU HAVE PHYSICAL ACTIVITY?

1234567
YOUR MOST CONVENIENT DAYS TO WORKOUT? (Select all that apply)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
WHAT PART OF THE DAY DO YOU PREFER TO TRAIN?

MorningNoonAfternoonEvening
REALISTICALLY, HOW OFTEN YOU PREFER TO TRAIN EACH WEEK?

1x Per Day2x Per Day3x Per Day4x Per Day
FOR EXERCISE, BETWEEN WHAT HOURS FIT YOUR SCHEDULE BEST? PLEASE LIST HOURS IN SEPARATE BOXES. (E.g. 9:00 - 11:00am, 5:00 - 8:00pm)
PLEASE LIST YOUR MOST FAVORITE TYPES OF PHYSICAL ACTIVITIES. (E.g. Running, Outdoor Volleyball, Basketball, Boxing)
HAVE YOU EVER USED AN IN-HOME EXERCISE PROGRAM? IF SO, WHAT TYPES. (E.g. P-90x, Insanity, PiYo, Beachbody, Zumba, Tae Bo)
DO YOU PREFER TO EXERCISE?

InsideOutsideCombination of BothDoesn't Matter
IN WHAT FORMAT DO YOU PREFER TO TRAIN?

Personal TrainerLarge GroupSmall GroupAloneClassesDoesn't Matter
WHAT TYPE OF EQUIPMENT HAVE YOU USED BEFORE? CHECK ALL THAT APPLY.

Nautilus MachineFree WeightsTreadmillVersa ClimberStairmasterEllipticalCablesBosu BalanceMed BallsJump RopesBattling RopesSpeed LaddersTRXBandsKettlebellsStationary Bike
CHALLENGES
WHAT ARE THE CONSTANT CHALLENGES THAT KEEP YOU FROM WORKING OUT? CHECK ALL THAT APPLY.

Keep hitting a plateauUnplanned meetings at workLack of motivationNo timeMinimal financesA little self-consciousUnsatisfied with previous resultsShortage of equipmentDon't know where to begin
DON'T SEE YOUR REASONS, IN A FEW SENTENCES, SHARE THE CHALLENGES YOU EXPERIENCE. (The box expands as you type)
PRESENTLY, AT THIS TIME IN YOUR LIFE, WHAT PHASE DO YOU CONSIDER YOURSELF TO BE IN?

I'm a beginner, starting my first exercise routineContinuing a prior routine, after a lay-offI only go 1x per week, thinking about switching gymsJust canceled a membership, taking a break for nowRecently joined a new club, it's my 1st week, I'm excitedLooking for new options, I'm openBeen working out 1 - 2 months consistentlyBeen working out 3 - 4 months consistentlyI'm on a roll, been working out consistently 6 + monthsI'm not working out right now
ASSUMING YOU'RE ACTIVELY EXERCISING, OR PREPARING TO START, WHAT WOULD YOU LIKE TO ACCOMPLISH? CHECK ALL THAT APPLY.

Reduce body fatTone musclesIncrease flexibilityBuild muscle massIncrease motivationDecrease post-natal effectsGet variety of exercisesRehabilitate an injuryLose weightCreate a habitGain more energyBe ready for an event
FITNESS MEMBERSHIP
WHAT HEALTH CLUBS ARE YOU CURRENTLY A MEMBER OF? (Check all that apply)

24 Hour FitnessLifetime FitnessL.A. FitnessLarry NorthEquinox FitnessCross FitEnergy Fitness
OTHER CLUBS NOT LISTED
FOR HEALTH CLUB MEMBERSHIP, WHAT IS THE MINIMUM & MAXIMUM YOU'VE PAID PER MONTH?
MINIMUM
MAXIMUM
HAVE YOU EVER BEEN A MEMBER OF A FITNESS STUDIO

YesNo
IF SO, PLEASE LIST LOCATIONS
FOR A FITNESS STUDIO, WHAT IS THE MINIMUM & MAXIMUM YOU'VE PAID PER MONTH?
MINIMUM
MAXIMUM
EXERCISING AT A HEALTH CLUB OR STUDIO, WHAT CLASSES DID YOU TAKE?

Cycle or SpinBoot-CampYogaPilatesDanceBarrePersonal Training
OTHER CLASSES NOT LISTED
HAS/IS YOUR FITNESS CLASS PARTICIPATION BEEN?

A one time thingOff and onAt least 1-2x per weekOften 3-4x per week
IN A CLASS, DO YOU PREFER THE SAME INSTRUCTOR?

Not reallyPreferably soAbsolutely yesNo opinion either way
HAVE YOU EVER PARTICIPATED IN A FITNESS EVENT

YesNo
IF SO, LIST THE EVENT NAMES
ASSUMING YOU'VE BEEN A HEALTH CLUB MEMBER BEFORE, WHAT DID YOU LIKE ABOUT THE ENVIRONMENT. (The box expands as you type)
SHARE WHAT YOU DISLIKE ABOUT THE ENVIRONMENT. (The box expands as you type)
PRICING
AT PREVIOUS RESIDENTIAL PROPERTIES YOU'VE LIVED IN, DID THEY OFFER A HEALTH & FITNESS PROGRAM?

YesNo
IF OFFERED NOW, WOULD YOU PREFER FITNESS CLASSES?

In the morningAfternoonIn the evening
FOR A HEALTH & FITNESS PROGRAM, WHAT'S THE MAXIMUM YOU WOULD PAY PER MONTH?

$10$20$30$40$50$60$70$80$90$100
Should be Empty:

DEMOGRAPHICS

HEALTH BACKGROUND & HISTORY

LIFESTYLE

EXERCISE

CHALLENGES

FITNESS MEMBERSHIP

PRICING