UFIT Lifestyle Fitness Assessment

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone NumberOptional

Area Code

Phone Number

5

What is your exercise lifestyle?

Sedentary

Competitive Exercise

Moderate Exercise

Body Building

6

How many hours of sleep do you get?

less then 4 hours

4-5 hours

5-6 hours

7-8 hours

7

What type of Beverages do you consume?

8

Any major surgeries that would prevent you from exercising? If so please explain.

9

Are you currently following any nutritional meal plan?

YESNO

10

How many balance meals are you consuming each day?

11

Are you taking any Nutritional Supplements?

YESNO

12

How is your overall Wellness?

Poor

Good

Fair

Very Good

13

Do you see your Doctor for regular checkups?

YESNO

14

List your current age, height and weight.

15

If we can match you up with one of our programs would you be willing to commit and get started today?

YESNO

16

Any additional comments that you would like to add.

17

Please verify that you are human* This field is required.