Screen Fitness Wellness Evaluation
Please be as accurate and detailed as possible.
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Name *
Address
Email *
Phone Number *
Date of Birth (mm/dd/yyyy) *
Height *
Weight *
What are your goals? *
be as specific as possible
How many days per week are you willing to commit to exercise? *
How many hours per day are you willing to commit to exercise? *
Physical Activity Readiness Questions
Has your doctor ever said that you have a heart condition? *
Required
Do you or have you ever had chest pains? *
Required
Do you lose conciousness or lose you balance as a result of dizziness *
Required
Do you have a bone or joint problem that can be aggravated by physical activity? *
Required
Are you currently taking medication for blood pressure or any heart condition? *
Required
Is there any medical reason that would prevent you from exercising? *
Required
If you answered yes to the above medical questions please explain in detail
Wellness Evaluation
I rate my current fitness level as
never exercise
best conditioning
Clear selection
Do you smoke
Do you eat breakfast
Do you have diabetes and or do you have a family history of diabetes
Do you drink 64 ounzes of water everyday
How many hours do you spend per day watching TV, surfing the web, and chatting on the phone?
Are you willing/able to commit 100% to follow a personalized exercise and nutrition program?
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