Wellness Intake Form
Wellness Intake for Intro Offer
Welcome! and what is your name?
Where did you hear about our intro offer?
A friend who goes to the studio
A family member
What made you decide to take our intro offer?
Why today (and not 1, 3, 6, etc months ago...or not 1, 3, 6 etc months later)...why now? Did something happen to make you take action now?
How do you feel about the possibility of starting/changing/continuing exercise?
I'm so excited!
I'm kind of nervous or afraid
Not sure I really want to do it!
I have a lot of questions!
Have you taken a class at StudioTimeOut yet?
Yes but not for a long time
If you HAVE taken a class at the studio, which class, how did it go for you....did it meet your needs? Did you like it? Do you wish something was different about it?
What are you hoping to get from exercise?
Get more flexible
Lose body fat
Decrease blood pressure
Decrease anxiety/depression/improve mental health
Tell me more about your wishes/goals for exercise and health. Anything specific you are wanting in terms of physical, mental or lifestyle goals/changes?
Have you tried other studios, gyms, fitness facilities?
Yes I go now to a gym or studio
Yes, I've tried in the past but don't go now
Yes I have a membership but I don't go
No, I've never been to a gym or studio before
I don't go to a gym but i exercise at home, outdoors or any other method that does not involve a gym or facility.
If you have NOT been to a gym or studio, what has stopped you?
I just don't like the idea of going to a gym or studio
It's not my style
The smell bothers me
Too many people
It feels impersonal
I wouldn't know what to do
I've never considered it....just don't think about it
Anything additional you'd like to share about why you have never gone to a gym or studio before?
If you HAVE tried a gym or studio, did it work for you or not?
Yes it worked great and I got the results I was looking for
Yes it worked but I fell off my routine
No because I didn't go or give it a chance
No because I didn't like it and did not want to go
Anything you want to add/explain about your past experiences going to gyms or studios?
Tell me about the time you have for exercise
I ONLY have very early weekday mornings available for exercise. No other time EVER works for me.
I have a very flexible schedule and can attend classes most anytime
I prefer to attend classes weekday mornings
I work weekdays and can come to classes in weekday evenings
I can come to classes on weekend mornings
I only have weekday early-mid-afternoons available for exercise.
Anything you want to explain more about your available time for exercise?
Do you have support for you exercising (spouse, kids, parents, neighbors, roommates, etc)?
No, I have no support
No I have not only no support, but I have someone sabotaging my efforts to get healthy
Anything else you want to explain about who is or is not supporting you in your efforts to exercise and/or get healthy?
Everyone has something with the potential to stop them.What obstacles do you see standing in your way?
Lack of time
I don't like the way exercise feels
Too many other people needing my time
Long hours at work
Lots of travel
I have trouble staying with a program
I don't believe I can really get the results I want
I just don't want to exercise and do what it takes
I don't have any obstacles
How long has it been since you've felt like you were in ideal shape?
I've never been in good shape
5 years ago
10 years ago
over 20 years ago
I'm in the best shape right now
Anything else you'd like to add about when you've been in shape?
If you were in good shape in the past, what were you doing then and who were you doing it with?
If you stopped....what triggered you to stop?
How long have you been thinking about change or reaching your fitness goals?
How serious are you about conquering this and making it happen?
Not at all
If not a "10" why not?
What joint problems do you have?
Low back trouble
Do you have any of these?
Osteoporosis or osteopenia
Anything you would like to add about physical issues affecting your ability to exercise?
If you can imagine what your life would look like when you achieve your goals, how will you feel? How will your life change? What will you do?
Send me a copy of my responses.
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