Name

Email Address

Phone

I am interested in (or have had a doctor recommend) one or all of the following activities: I am interested in (or have had a doctor recommend) one or all of the following activities: General fitness (strength training, cardiovascular exercise) Yoga, Range of Motion and Flexibility Injury and Fall Prevention Exercise and/or Meditation For Stress Management Exercise for increased bone density (including recent diagnosis of Osteopenia or Osteoporosis) Weight loss or generalized fitness-related nutrition guidance Yoga-based health coaching General nutrition guidance and accountability

Age Age 18-35 36-50 51-64 65+

Gender Gender Male Female Non-binary I'd prefer not to say

Please list your personal interests and favorite physical activities

To the degree that you are comfortable, please tell me about injuries or illness you have been, or are currently experiencing (this is helpful, but not required now)

What do you do for work? If retired, simply write retired

On a scale of 1 - 5, how committed are you to beginning a fitness program? On a scale of 1 - 5, how committed are you to beginning a fitness program?1 - Only Browsing2 - I know I need to change but I'm not sure if I'm ready yet3 - I am interested in getting in shape, but I'm taking my time4 - It's probably time to change, and I'm curious to learn more.5 - I'm actively looking for a coach and I'm ready to go!

Do you have any other questions or concerns you'd like to address in our first session?