Silver Survey

Silver Questioniare

* Indicates required field

Name *

email address *

Who recommended you? How did you hear about us? *

1.) Check all that applies to your health and fitness goals *

Gain Muscle Lose Fat Maintain Current Weight Get Ripped Improve overall Health

What's your Health and Fitness Goal *

What's your estimate height and weight? *

What is your target goal date? *

2.) Do you have any current or previous heart conditions? *

Yes No

3.) Do you smoke? *

Yes No

4.) Do you have any bone or joint issues? *

Yes No

If yes, explain *

5.) What's your exercise level? *

Beginner Intermediate Expert

6.) Are you over the age 65? *

Yes No

7.) Do you have any conditions that would require a Doctor's clearance? *

Yes No

If yes, explain *

8.) Do you lose balance, get dizzy, or lose consciousness during physical activity *

Yes No

9.) Do you experience chest pain or shortness of breath during physical activity? *

Yes No

10.) Are you prescribed medication for blood pressure or a heart condition? *

Yes No

11.) Are you, or have you recently been pregnant? *

Yes No

If yes, please describe *

12.) Do you access to a gym? *

Yes No

13.) List gym equipment that you have at home *

jason@getrightresults.com