Request edit access
Fall 2021 Intake Survey for Online Adaptive Training
Adaptive online personal training (BCMOS)
Sign in to Google to save your progress. Learn more
Email *
Your full name
phone number *
Emergency Contact *
Your level of injury/ category of your disability (for ex. C6 quad)
Do you currently have some type of daily stretch or exercise routine?
Clear selection
On a scale of 1-10 (with 10 feeling the most satisfied with your health), where do you rank yourself at this given time in your life?
I am very dissatisfied with my health
I am the most satisfied with my health
Clear selection
If you knew that you would succeed at any fitness or wellness goal you set for yourself, how motivated 4would you be to start?
Very unmotivated
Highly motivated
Clear selection
5. If you were given a free gym membership today, how motivated would you be to start using it?
8
Clear selection
If you had access to a workout buddy, on a scale of 1-10 how motivated would you be to utilize them?
Very unmotivated
8
Clear selection
On a scale of 1-10, how motivated are you to work out at a public or private gym facility (if accessible)?
Very unmotivated
6
Clear selection
On a scale of 1-10, how motivated are you to work out at your home?
Very unmotivated
8
Clear selection
Are you willing to get up a bit earlier or go to sleep a bit later in order to achieve your health and fitness goals?
Clear selection
I often worry about why I won’t hit my fitness goals, and I tend to focus on why something probably won’t work.
Clear selection
I am unsure of my abilities to achieve the health and fitness goals that I set for myself.
Clear selection
If I work hard in the gym and stick to a training regimen, I am confident that I will be successful.
Clear selection
I find it a challenge to find the time to stick to any exercise or stretch routine.
Clear selection
To me, exercising feels like a chore.
Clear selection
When I am unable to get in my planned exercise or stretching, I feel like a failure.
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Ocean Rehab and Fitness. Report Abuse
Google Forms