Name *

First Name

Last Name

Phone Number *

(###)

###

####

How would you describe your exercise frequency? *

A few times a month

Once a week

3-5 times a week

Every day

How would you describe your satisfaction in your exercise frequency? *

I am satisfied with my current frequency

I would like to exercise more frequently

If you would like to workout more frequently, what are your barriers to exercise? *

Please check a maximum of three and ensure the number one reason is included.

Time

Child care

Low energy level

Space (lack of gym membership or at-home equipment)

Low desire or motivation

Low accountability

Finding an enjoyable mode of exercise

How would you rate your satisfaction with your cooking and meals? *

I am satisfied with my eating habits

I would like to incorporate more fruits and vegetables in my diet

I would like to incorporate more variety in my meals

I would like to do b. or c., but it’s too expensive or timely

I would benefit from, attend or use (check all that apply): *

A list of easy, affordable healthy meals with a grocery list

A supplemental exercise list or routine to do at the gym

A list of exercise suggestions tailored to my goals and interests (e.g. muscle building, energy sustainment, focus, balance, etc.)

Accountability in my workouts

A workout led by staff once a week

I struggle with (select all that apply): *

Low back pain or joint pain

Fatigue or drowsiness

Low motivation

Low self-confidence

Anxiety

Being too happy in life

What your favorite type of exercise?

Yoga/Pilates

HIIT (High intensity interval training)

Endurance Cardiovascular

Muscle Training (Lifting Weights)

Circuit/Boot Camp Group Exercises

I am interested in learning about how exercise and diet affects the options in the previous question. *

True

False