Improve My Fitness

First Name *

Last Name *

Phone Number *

Email *

Date of birth *

Usual Weight *

Goal Weight *

How many times do you exercise in a week? *

Have you ever had any surgical procedures done? *

Yes

No

Name those procedures if any *

Name any recent injuries *

Did you play sports in high school? *

Yes

No

Do you smoke cigarettes? *

Yes

No

How many times do you smoke in week? *

0 times

1-2 times

3-5 times

6 or more times

Do you drink alcohol? *

Yes

No

Do you have any medical conditions that could hinder your fitness journey? *

How many hours of sleep do you get per night? *

How many hours do you spend watching tv, Hulu or Netflix per day? *

Any Questions For Me?

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