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Silver Questionnaire
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Name
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First
Last
Please be sure to match the info on file. Help us help you!
Email
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Please be sure to match the info on file. Help us help you!
What are your specific wellness Goals?
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This will live as a reminder of your WHY throughout your journey with us.
To the best of your knowledge, what is your current height and weight?
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What is your target goal date?
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What's your goal weight?
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2.) Do you smoke?
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Yes
No
If "yes," please specify:
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1.) Do you have any current or previous health conditions or limitations?
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Yes
No
4.) Are you over the age 65?
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Yes
No
3.) What's your exercise level?
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Beginner
Intermediate
Advanced
5.) Do you have any conditions that would require a Doctor's clearance?
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Yes
No
6.) Do you lose balance, get dizzy, or lose consciousness during physical activity?
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Yes
No
7.) Do you experience chest pain or shortness of breath during physical activity?
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Yes
No
8.) Are you prescribed medication for blood pressure or a heart condition?
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Yes
No
9.) Are you, or have you recently been pregnant?
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Yes
No
If "yes," please specify which condition:
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10.) Do you access to a gym?
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Yes
No
List gym equipment that you have at home.
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