Fitness History

Name*

First Last

Email*

Phone*

Age*

Occupation*

Current Weight*

Height*

Highest Adult Weight*

Excluding pregnancy.

Lowest Adult Weight*

Desired Weight*

Have you ever walked for exercise?*

Yes
No

When?*

How often?*

What type of results did you get?*

Are you currently doing any type of exercise?*

Yes
No

Please list ALL types of exercise you are currently doing, how much, and how often you do it. (example: yoga, 30 min, 5 days a week)*

Have you exercised in the past?*

Yes
No

Please list ALL types of exercise you have done, how much and how often you did it, and the time period that you were doing this. (example: Spinning class, 60 min, 3 times a week, summer 2012-fall 2013)*

What obstacles may make it difficult for you to exercise regularly?*

Is weight loss one of your goals?*

Yes
No

Have you lost weight in the past?*

Yes
No

How much?*

How did you do it?*

What are your health and fitness goals?*

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My Walking Coach

with Michele Stanten

Fitness History

Thank you for your interest in personal coaching!

I would like to help you achieve your health and fitness goals. Please complete the following form so that I can design a personalize plan for you.