Request edit access
You DESERVE a Personal, Simple & Easy Wellness Plan That Works For YOU!
Hi and welcome! My name is Laura Mutz, founder of Chizel Fitness based in Ship Bottom, NJ. I've been a certified fitness instructor for over 30 years and I'm excited to have the opportunity to expand my reach outside of studio to assist others in meeting their fitness/wellness goals. In order for me to serve you please fill out and submit the short form below. I'll be in touch with you once I've evaluated the information. Thanks for being here- Be Fit, Be Well!
What Gender Are You? *
What is your age? *
Your answer
What is your height? (feet/inches) *
Your answer
What is your current weight? *
Your answer
What do you feel is your ideal weight? *
Your answer
How is your diet? Please tell me a little about it: *
Your answer
What dietary improvements would you like to make? *
Your answer
What dietary supplements (vitamins/superfoods) are you currently using? *
Your answer
If you work, what kind of job do you have? (sit at a desk, laborer or something in between?) *
Your answer
What about structured exercise? How many times a week and what do you do? *
Your answer
Regarding physical fitness, what would you like to improve?(strength, endurance, flexibility, etc) *
Your answer
On a scale of 1-10 (10 highest), how committed are you to making the changes you need to meet the above goals? *
Your answer
How soon would you like to start? (today, next week, etc)? *
Your answer
What is your name? (first and last please): *
Your answer
What is the best email to reach you? *
Your answer
What is the best phone number? I'd like to call you once I evaluate your questionnaire- it's much easier to talk than type! *
Your answer
Who is the person who referred you to this program? (first and last name please) *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy