Just fill in the applications below and our team will contact you.
Data Collection Sheet
Your name*
Today´s Date*
Date of Birth*
Age*
Email
Phone Number*
Weight*
Height*
Occupational Questions
All answers are required*
1. What is your current occupation?*
2. Does your occupation require extended periods of sitting?* YesNo
3. Does your occupation require extended periods of repetitive movements?* YesNo
4. Does your occupation require you to wear shoes with a heel (dress shoes)?* YesNo
5. Does your occupation cause you anxiety (mental stress)?* YesNo
Recreational Questions
1. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)?* ReadingGardeningWorking on carsExploring the internetOther Explain Other:
Medical Questions
1. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?*
2. Have you ever had any surgeries? (If yes, please explain.)* Yes, please explain:
3. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.) YesNo Yes, please explain:
4. Are you currently taking any medication? (If yes, please list.)* YesNo Yes, please list:
Motivation / Change
1. On a scale of 1-10 how hard do you want to be pushed?* 12345678910
2. Have you ever worked with a trainer before?* YesNo
3. What did you like most about your trainer?
4. What areas of your body do you want to improve the most?*
5. When is the last time you exercise for an hour?*
6. What type of exercise was it?*
