Your Name (required)

Your Email (required)

What's motivating you to look into a Fitness Center at this time?

Do you like the idea of Women Only?
ChooseYesdoesn't matter

How long have you been considering making a change?

Previous exercise experience?

Did you reach your goals?
YesNo
If No, why not?

Scale 1 - 10. How committed are you to making changes to improve your health? 1 not very - 10 very.
Choose10987654321

Specif Goals that you want to accomplish:

How much time can realistically invest?
days per week Choose7654321
time per visit? Choose2 hours1.5 hours1 hour.5 hours

Medical Challenges
Check all that apply:
High blood pressure Diabetes Respiratory Asthma Other 
Other (if applicable)

Medications that cause dizziness?

Physical Challenges:
Choose Back Knees Other  Other:

Smoke?
ChooseYesNo
If yes, how many cigarettes per day?

Specific to her needs:
Check all that apply:
 interested in trial workout with a staff member. interest in classes. location work for her. family supportive of her plan to start working out. do you have the services she's looking for.

Basic Concerns:
Check all that apply:
 will someone help me? my size, am I too large. fear of failure/commitment. no motivation injury/will I be pushed too hard other

Other (if applicable)