Name *

First Name

Last Name

Phone number? *

(###)

###

####

Improving overall health *

1

2

3

4

5

6

7

8

9

10

Gaining muscle *

1

2

3

4

5

6

7

8

9

10

Losing weight *

1

2

3

4

5

6

7

8

9

10

Improving functional movement *

1

2

3

4

5

6

7

8

9

10

Reducing the risk of injury/illness *

1

2

3

4

5

6

7

8

9

10

Enhancing sport performance *

1

2

3

4

5

6

7

8

9

10

Reducing/coping with stress *

1

2

3

4

5

6

7

8

9

10

Reducing/coping with anxiety *

1

2

3

4

5

6

7

8

9

10

In the past 2 weeks, how often have you completed 20+ minutes of moderate to intense exercise? *

None

1-2 times a week

2-4 times a week

5+ times a week

Do you often wear high heels for extended periods of time?

Yes

No

In the last six months, which of the following has kept you from exercising? *

Select all that apply

Lack of location/facility

Lack of transportation

Lack of equipment

Lack of time

Lack of knowledge

Monetary cost

Feelings of inadequacy

Anxiety surrounding your physique

Ambivalence

Illness/injury